GW1-2023-01038_Well Construction - GW1_20230125

WEU CONSTRUCTION RECORD (CW 1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips ER ZONES ;•
Well Contractor Name FItoM TO DRSCRIMION
3441 A �. rt. ,a,3 d ft. S ;i I
NC Well Contractor Certifcniion Number
15,OUTER CASING for multi-cased wt:lls OR LINER if n licnbla
NW Poole Well and Pump Company room To DIAMETER I' TIIICItNESS MATERIAL
Company Name F tt. ft. in• c0 a S— C'let I V
16.INNER CASING OR TUNING( eotliermal closed-loon)
2.Well Construction Permit#: 3� 7 o r 1 FROM TO DIAMETER! THICKNESS MATERIAL
List all applicable ireAconstrucilou peralts(i.e.U1C,Coutty,State,Y rlatde,etc.) ff. ft. in
3.Well Use(checicwell use):- ft.
Water Supply Well: 17:SCREEN.
❑A riCUllUral FROM TO DIAMETER SLOTSiLE THHCKNFSS MATERIAL
g ❑Municipal/I ublic fL ft. In.
❑Geothermal(1-lealing/Cooling Supply) residential Water Supply(single)
ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑ n- ate ❑Wells> 100,000 GPD FROM To MATERIAL EMPLACEIIIENT METHOD&AINIOUNT
Non-Water SupplyWell: U. ft. 0�0 ft.
❑Monitoring ❑Recove loll t �UJ�
Injection Well:
rY ft. R.
❑A uifer Recharge tt, ft.
q g ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ifa licablc
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test G;❑StorintivatcrDrainage ft. fc.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal{Closed Loop) ❑Tracer ZU,DRILLING LOG attach ndditionnl sheets if necessary)
❑Geothermal(Heating/Cooling Return). ❑other(explain under#21 Remarks) rROM TO DESCRIrr1ON color,hnrdnas,Soil/rock type, rnin size,etc.
ft. ft. 1 S
4.Date Well(s)Completed:_�� ' -�..) Well IDW a
ry
.. G ri. c•.+.p Jt'rrels r
51.Well Location: S— [f 36 S [f art, t~A�"' C
ft. rL JA N
Pncility/Ownicr"Nnmc racility IDH(if applicable) ft. ft.
)C I�I Cinr 'd J' ft. in, s rrx:,,,, f iY:. "'og u
�_ t'•I41 trtl
Physical Address,City,mid Zip - ", ft. Ct
Ta Gn(C-1 t rt 21.REMARKS
County Parcel Identification No.(PiN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one ladlo„g is sufcicnt)I:i i ;1
�� -1 22.Certificad
•9�3 "1�? N _" l LtO�-I �0 yy
6.Is(are)the well(s): bl'ernianent or ❑Temporary Signature ofCertificd Well Contractor Date
By signing this form,l hereby certify dear die u'ell(s)trnr(u ereJ constructed is nccordanc a+rich
7.Is this n repnir to an existing weli:` ❑Yes •,01'.•- nNo ISANDiC 02C.0100 or/3A NCAC 02C.600►Iced Construction Stondardt and dml a calm•
If INN is a repalr,fill out knoien well construction information aid erplahi the nature of tha of dBs record has been provided to the ire/l o,rnet:
repair under#21 reutorkr section or on the back of dds jorn1.
23.Site diagram or additional well details:
8.For Geoprobe/DI'T or Closed-Loop Geothermnl,}Weils having the same You may use the back of this page to provide additional well constriiction 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
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 36's (ft)
/•'a•��rlriple-u'allsllsialldeprhsjdiperent'(example=3n1o0•'.and2©100') Submit this.GW-1 within 30 days of well icompletion per thefollowing:
10.Static water level below top of easing: ? 24a. For All Wells: Original form to Division of Water Resources (DWR),
If,roter level is above cosing,use' i•" (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Iniection Wells: C•t : DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleig ;+'N hC'27699-1636
-
12.Well construction m method: Rotary
(i.e.auger,rotary,cable,direct pusli,e(c:) 24e.For Water Supp►v n»d Open-Loop Geothermal Return Wells•Copy to[lie
county envtrontncup health department of the county where installed
FOR WATER SUPPLY WELLS ONLY- ''' " ''' 1 '
24d.For Water Wells nroducint:over 100.000 GPD•Copy to DWR,CCPCUA
i3a.Yield(gP+=t) BLOW Permit Program,1611 MSC,Raleigh,NC 2769.9-1611
Method of test:
e
13b.Disinfection type: HTH 1 Ib.Amount:
romi GW-I North Carolina Department orEnvironmental Quality-Division of Water Resources trvterd r.r,)ni a