GW1--03106_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Con tractor Information:,:
Landon Phillips
14.WATER ZONES
Well Contractor Nemc FR06, TO MCRIFFlOrt
3441 A
NC Well ConunctorCertification Number 37v -
15,OUTER CASING for multi-cos vells OR LINER if n licnblc
NW Poole Well and Pump Company rA( To Drnn,srER T,,,CravEss n,ATEaI``nt
P y l-t ". '� ft. (�j in. 6a� �al v
Com an Namc
16.INNER CASING OR TUDING(geothermal closed-loon)
2.Well Construction Permit N:_-2 FU 7LL6 FROM TO DIAMETER __F_T_H_ic_K_N_E­ss­__l MATERIAL
List all applicable well construction pennus(i.e.U1C,Cmauy,State,Parlance,etc.) ft. ft. in
3.Well Use(check well Ilse):
Wa7invec
l: 17:SCREEN.
❑A FROM TO DIAbIETER SLOTSIZE THICKNESS MATERIAL
❑Municipal/1 ublic it ft. in.
❑Ging/Cooling Supply) residential Water Supply(single)
ft. ft. in.
❑lttrcial ❑Residential Water Supply(shared)
18.GROUT
❑I ❑Wells>100,000 GPD I7tOM1f TO MATEIAL EM1iPLACE5IENI M1lErfiOD 6 AOrOUNT
Non-Water Supply Well: C) ft. of ft.
❑Monitoring ❑Recove
ry. ft. ft.
Ltjectinn Well:
❑A uifer a ❑Gro Recharge ft. ft.
q g undwater Rctncdiation
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACK ifa licnblc
❑SalinityBarir FROM TO 5ATERIAL EM1SPLACEIlENT11IE1710D
❑AquiferTcst I:. I;I i bStorintvatcrDraina c ft. ft.
[]Experimental Technology ❑Subsidence Control tr. ft.
❑Geothermal(Closed LOOP) ❑Tracer
i 20.DRILLING LOG Attach ndditionnl sheets if necessary)
❑Geothermal(1-leating/Cooling Retum) ❑other(explain under N2l Remarks) FRoaI To DESCRIFrION color,bnrdness,sail/rock type, rain size,etc.
D ft. ft. /
(G'
4.Date Well(s)Completed: ,2—Z Z?'Well IDN / .
5rr.Well Location:
Ili, l )I�T ft.* �y rrl� r° HR 2 S
Pacilily/OrvncrNnmc ,i ft. ft.Facility JDl!(ifapplicable) I _
s �1 } s�lI e (lc�
Gn,1 dJ r;: �'�f��c• � Ic. ft.
Physical Address,City,and Zip " '' P'• ft. ft.
lGf/1�C�I to 21.REMARKS
CO11(y Parcel identification No.(PiN) Used hardened steel drive shoe.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwcll Field,one lat/long is.su(TcicnQ 22.Ccrti(icati
6.Is(nri:)ilia well(s): ❑lsermnnent or ❑Temporary Signaturc ofCcn(ficd Well Contractor Date
'.'`1' I`�' Uysigning this farm,/hereby cert jy that r c,ii-ell(s)Iras(irere)consiructed in accordance Irith
7.Is this a repair to an existing well: .. bYcs: lii'. bNo 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Consiruction Standards and that a capr
If this is a repair,fill out knou n trell constrclion irrforivatlon mad explaln due nature of the of this record has been provided to the bell olrner.
repair under iD21 rernanlr section at-oil the back of tilform ls .
I 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geotherm„al,}Vells having die same You may use the back of this page to provide additional well construction info
construction' only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovice in Remarks Box).You may also attach additional pages if necessary.
drilled:+
24.SUBMITTAL INSTRUCTIONS
9.'I:ol:tf well depth below land surface: (Ct)
ran•uniirlplen-ells list fill deplhsifddereni(6 [e-mail]2@100') Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water level below to of cnsin 24a. For All Wells: Original form to Division of Water Resources (DWR),
ljuatcr level is above casing,Ilse"P" Sr I (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole dinrnctcr: 6 (in.) 24b.For Infection Wells: Copy to DWR, Underground Injection Control(IUC)
p ;' Program,1636 MSC,Raleigh,NC 27699-1636
12.Well coils true tion'mcthod: Rotary
(i.c.auger,rotary,cable,direct push,etc.) 24c.For Water Sun ply and Onen-Loop Geothermal Return Wells:Copy to 11'te
i, county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: t.''"' J+!T,L'''
24d.For Water Wells producing over 100.000 GPD•Copy to DWR,CCPCUA
13a.Yield(gP 111) 111ctltod o f test
BLOW Pcrmlt Program,1611 MSC,Raleigh,NC 27699-1611
'� :
, u sal
13b.Disinfection type: HTH 1 Ib.Amount:
Fonn GW-1 North Carolina Department oCEnvironmental Quality-Division of Walcr Resources RPvicad r,.r,--rn l r