GW1-2021-07190_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14'.;,WATER ZONES ,'
Well Contractor Name FROM TO I DESCRIPTION
3441 A /30 ft. /3 5" "' bo
ft. ft+
NC Well Contractor Certification Number
_45.OUTEFUCASING(for ' sd*L)fji='"Mcabk)
FROM �TO U
N.W. Poole Well & Pump Co. THD ETER.1 MATERIAL
Company Name 5 ft. I/Abolft. 1 .1���i-- I ,lar I CALV.
16.LNNER CASING',.OR TUBING(ji6thirinid elbsed-loop),
2.Well Construction Permit#: 6701 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits rt.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): f, ft. in.
Water Supply Well: 417.SCREEN
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
CAgricultural OMunicipaVPublic ft. ft. in.
DGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in.
OlndustriaUCommercial DResidential Water Supply(shared) f18.GROUT..
01rrigation oWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e ft. do ft. ?Jr'T'AP i TF- !pdo fir D
oMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge OGroundwater Remediation
'.19.'SAND/GRAVEUPA (if aiiPlicable)
CAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT I METHOD
[]Aquifer Test OStonnwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 7-
_20.3 DRILLING LOG(gthicWadditimaAlsb6its if necessmy).�__�,
OGeothermal(Heating/Cooling RetuT) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type, rains etc.)
'0 ft ft.
4.Date Well(s)Completed: 7//4 /well ID# --3y-ft. el R.
SAvh t ct,44
Sa.Well Location: it- ft- SLATE
j-c4sTiN ?'Olfrs ft. ft. �Nltu
Facility/Owner Name Facility ID#(if applicable) ft. ft.
470 eAflRoL Rb SE"A, 275% ft. ft. I
Physical Address,City,and Zip f ft. ft.
�11.'REIWARKS- iptuqe�6�0
County Parcel Identification No.(PIN) Used hardened stedrW6-%W S
ec
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lattlong is sufficient) 22.Certificati
35a6-7Y97 N ::11.3 1(00(0 W 19'/;P
711,0c a a
6.Is(are)the well(s): Permanent or OTemporary Siifnature of Certified Well Contractor Date
By signing this form,I hereby certify that the well was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or *0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the 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 Over'in Remarks Box).You'may also attach additional pages if necessary.
drilled: I C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ilf-5* (ft)
For multiple wells list all depths lidifferent(example-3@200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),If water level is above casing,use
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameten. y (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Su pply and Open-Loop Geothermal Return Copy to the
- a s
�enviro�nmentai health department of the county where inNi'e-W
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 60 Method of test: Permit Pr_gm o ,1611 MSC,Raleigh,!NC 27699-1 61 1
13b.Disinfection type: #7)* Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 18