GW1--03072_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Cori tractor Information:
Landon Phillips 14.WATERZONES
Well Contractor Name I FROM TO DESCRIPITON
3441 A
rt. It.NC Well Contractor Certification Number
15:OUTER CASING(for-multi-cased wells OR LiNER if n licnble
NW Poole Well and Pump Company FROM TO DInnIETER TANESS nATERIAL
Company Name ( ft a ft. in• /rJ..Z C f
16:INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: _J vJ�'y o 7(�g� z�L FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(cliecli well use): ft. ft. in.
Water Supply Well: ;171+SCREEN.
FRohf TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
ft.-I&GROUT
❑Irri alion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEa7ENT METHOD&AMOUNT
Non-Water Supply Well: O ft. a fL �U��
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft.❑A uifer Recharge GroundwaterRemediation ft.
❑Aquifer Storage and Recovery 193AND/GRAVEL PACK ffa licable
❑Salinity Barrier FROM TO MATERIAL EMPLACEl11E 5EETHOD
❑Aquifer Test „ ;i,❑StomiwaterDrainage R. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
L ;
❑Geothermal(Closed Loop) ❑Tracer ;:20:DRILLING LOG attach additional sheets if necessary)
❑Geothermal(IIeating<CoolingRetum) ❑Other(explain under#21 Remarks) FROM To DESCRIrTIONeolor,hnrdnns,soil/rock e, ainsize,etc.
� ft. fa l'J :25O .,�.
4.Date WCII(S)Completed: —Z Well ID#
5a.Well Location: ft t ft
rt. rt.
Facility/OwncrNmne Facility ID#(if applicable) ft. ft. j�—��+ '-rr
76 S �CC.,,L 1.�`) U 4 ( S l�1 Y (c t 9 A /�c rt. ft. /.� i.
Physical Address,City,hud Zip a 7 4°b 'I `. 'i i ft. M Q P R 2 023
21.REMARKS '
Used hardened steel drived� i-:�n ''rtirvy�> lint
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/siecorids or decimal degrees: V
(ifivell field,one]at/long is'suflfcient) .i i'll;',.s ; 22.Certificati
35. 13582c o N -18!;, �-t u W
6.Is(are)the wcll(s): 111'ermanent or ❑Temporary Signature of Certified Well Contractor Date
ily signing this form,I hereby certify that thetia,ell(s)was(svere)cotistriicied in accordance vilh
7.Is this a repair to as existing well: ❑Ycs or MNo 131 NCAC 02C.0100 or 15A NCAC 02C.0100 ifrell Construction Standards and drat a core
Ifthis is a repair,fill out known well constriction ii forination and eiplaln the nature of due of this record has been provided to the well oi+wier.
repair under 1121 remarks section or on the back of dds joroi.
C ,Trill 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wellshaving the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:+ �'''"il'''`' - 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '''I `) <
J
For multiple ivensllstdll'depthstfdifferelii'(dxbmpie=3@200'and2(a100') (ft Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water level below top'of casing: ,d ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If,rater level Is above casing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 '(in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary F. ; I:
(i.e.auger,rotary,cable,direct posit,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS OriLY:
24d.For Water Wells Producine over 100 D00 GPD: Copy to DWR,CCPCUA
13a.Yield tut BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) Method of test.
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2011]