GW1-2021-07325_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: e -
Landon Phillips
.14;iWATER ZONES-
Well Contractor Name FROM TO DESCRIPTION
3441 A 6 TIN ft. ft.
O
ft.
NC Well Contractor Certification Number sS09 ifEft' 2 P
()I\ OUTER CASING ed �LINERSSif a le
FROM I TO ET T"
N.W. Poole Well & Pump Co. sedl%\ "6i 1-11—E'lw
N0, ERIAL
41 219 1
Company Name W ft. ft. �in.
16.INNER.CASING.OR.. G IN646theinial¢lowed'
2.Well Construction Permit#:_4-w-C>q7-2 T- FROM — TO DIAMETER Tmockkks I MATERIAL
List all applicable well construction permits ri.e.UIC,County,Slate,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,'SCREEN A
DAgricultural CMunicipal/Public FROM TO DIAMETER �1 THICKNESS MATERIAL
ft. ft. in.
OGeothermal(Heating/Cooling Supply) PIG'sidential Water Supply(single) ft. ft.
01ndustrial/Commercial OResidential Water Supply(shared) 18,GRO
UT,
OIrrigation oWells>100,000 GPD FROM TO MATERIAL— EMPLACEMENT METHOD&AMOUNT
WNon-Water Supply Well: ft. 20 ft. �_ft
oMonitoring DRecovery ft. ft.
Injection Well:
OAquifer Recharge OGroundwater Remediation ft. ft.
:i,19.SAND/GRAVEL'.PACK(ifatii)H6blel- ;-.,�,.
ClAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL' I EMPLACEMENT METH OD
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer
FROM TO DESCRIPTION(color,hardness soiVrock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft ft.
2
4.Date Well(s)Completed:-7.-'(-/' Well ID# ft. 41 ft.
5a.Well Location: ft.FROM
ft.
T-C 6-
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
C re,_e 1264C.4, /z/C ft. ft.
Physical Address,City,and Zip 9 -760 ft. ft.
(A-
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: F_
(if well field,one lattlong is sufficient) 22.Certificati,
On a'3 N
6.Is(are)the well(s): Wimment or OTemporary % ofC a Contractor Date
By signing this form,I hereby certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or Offoll, 15A NCAC 02C.0100 or ISA 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 ofthe of this record has beenprovided 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 Gr I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:_ — a C-t-S 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths iidifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water level below top of casing: y (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwaler level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
'21ri+
12.Well construction method: 24c.For Water Supply and Op en-Loop Geothermal Return(i.e.auger,rotary,cable,direct push,etc.) Wells:Copy to the
,
county environmental health department of the county where in e M
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 00 Method of test: C-/ Permit PTO_V__1 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018