GW1-2023-01194_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: Q
1.Well Contractor Information:
Landon Phillips 14,WATER ZONES !
Well Contractor Name - FROM TO I DFSCRIPTION -
3441 A 17-5 1" l tU ft. (0 _711-l"
ft. ft.
NC PVcll Contractor Certification Nuulhcr
15.OUTER CASING for mull(-cased walls OR LINER if n licnblc
NW Poole Well and Pump Company FROM DIAMETER TnICICNESS MATERIAL
I. ( fl. l b I 1 It. In. t`Y ,�(U tiu�
Company Name I
�U���7 16.INNER CASING OR TUBING wolhernml closed-loot
1.Well Construction Permit H: FROM TO DIAMETER I THICKNESS I MATERIAL
list all apphcahle well construction pertdcs 0.0.UIC,Counq,,State,I'arlance,a/c.) ft. ft. in.
3.Well Use(cllecli well use). ft. ft, In.
Water Supply Well: 17.SCREEN
FROAI TO DIAMETER SLOT SI'LE THICKNESS MATERIAL
❑Agricuhurnl ❑Municipal/Public rt. a. In.
❑Gco(hernnal(Healing/Cooling Supply) AItesidential Water Supply(single) ft ft In.
❑Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
❑Irrl anion ❑Wells>100,000GPD FROAT TO MATEIIIA.L EMPLACEaIENTIHETHOD&AaIOUNT
Non-Water Supply Well: ft. cp, rt.
❑Monitoring ❑Recovery ft. rt.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remcdiation
❑Aquifer Storage and Recovery ❑ 19.SAND/GRAVEL PACK If nllenbleSalinity Barrier FROM TO I RIATEMAL L•h1PLACEafENTMETIIOD
❑Aquifct-Test ❑StonnwaterDrainage ft. fL
❑Hxperimenlal Technology j OSubsidence Control
❑Geothermal(Closed Loop) ❑'Tracer 20.DRILLING LOG nitacIt additional sheets Irnecessa
❑Geolhennnl(1-le,'niug/Cooling Return) ❑Other(explain under H21.Remarks) rR051 TO DESCRIF11ON color,hardness Soiurack type.grain slzc etc.
U ft. ft.
4.Date Well(s)Completed: 'JC- Z 'Well IDH ff. ft. C.
5a.Well Location: �� ft- GS ft. / ,V
(tiff
Facility/0wner Name !Facility ID8(ifopplicable) ft. rt.
ssg �r
� 5 P
Physical Adtbcss,City,and Zip
ft. a.
i +, 21.REMARKS f .�. �f:'_'y:s.;7 1�f::.
•��-r,�glQiU�7 .
County Parccl Identification No.(PIN)
Sb.Latitude rind longitude in degrees/minutes/seconds or decimal degrees:
(irwell field,one Int/long is sufficient) -
��jj 11 rtnA jj�� QQ�� (��]J�J �Gj� 22.Ccrlificat'
N �V.V7177 e
W7-196.Is(are)thewell(s): ®Permanent or OTeilipormy Sigature orCertiIld W.II Contractor _ " Date
8j•signing this for•ni.I hereby cert J,that the we//(v)seas(were)constructed In accordance with
7.Is this a repair to all existing well: ❑Yes.:j or, 8No ISA N01C 01C.0100 or 15A NCAC 02C.0100(Pell Const-rictlon Standards and that a copy
Ifthis is a rcpat•,fill out known well carrst•uctioa infom ation and explain rite nature of the oflhls record has been prodded to Ilse sill owner.
repair under 1121,renrarks section are on ilia back of ilds foils. ,
!I' 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Gcolher'nuil.Wells having the same You may use(he back of this page to provide additional well construction info
construction,only I GW-I is needed. lndicale,TOTAL NUMBER or wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: I;,I I'7 < 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `-QJ f(•
Foruuthiple u•cl/s list all dept/rs Ifdoercrrt(example-'3w 200'and 1@I00') ( ) Submit this GW-I within 30 days ofivell completion per(lie following:
�l
10.Static water level below lop of casing: w (fl) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1/)raterlerel Is above casing,use t information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C/ lilt,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.auger conslrcnble, method: 24c.For Water Su 1 and O gn-Loo GeolLgnml Rclunl Wells:Copy to the
(i.e.auger,rotary,enble,direct pusls,arc.) ;i county envlronmeMal health department o the county w(ere installed
FOR WATER SUPPLl(WELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpnl) v 11lctholl of test: Blow Penntt Program,1611 MSC,Rn engh,NC 27699-161 I
13b.Disinfection type: HTH Ariount: 1 lb.
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Form GW-I North Carolina Department orGuvironmenlal Quality-Division of Water Resources Revised 6.6-2018
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