GW1--03071_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information: j
Landon Phillips '
WN
Well Contractor Name DESCRIPTION
3441 A rt.ft.NC Well Contractor Certification Number
for mulli cased wells OR LINER if n licablcNW Poole Well and Pump Company DIAMETER T,HCKNESSMATEft. I in.' ( dCCompany Namc b - �
// �-2 16.INNER CASING OR TUBING cothermal clo3ed-loon)
2.Well Construction Permit#:_(TW— D7 8�7e- Zed 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable+cell con tntctorr pernllts(i.e.U1C,Comity,State,Vartance,etc.) ft. M in
3.Well Use(check well use): ft. ft, in.
Water Supply Well- 17:SCREEN.
❑A ricullural FROM TO DIAIIIEIER SLOTSILE UCKNFSS MATERIAL
g ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Kesidential Water Supply(single)
IDRILLING
ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
T
❑Irri ation ❑Wells>100,000 GPD TO MATERIAL EMPLACEMENT MEIMOD a AMOUNT
Non-Water Supply Well: . ft. If )❑Monitoring ❑R ftInjection Well:❑A uifer Rechar a , ft,q g ❑GroundwaterRemediation
❑Aquifer Storage and Recove /GRAVEL PACK ifn licablerY ❑Salinity Darner TO BIATEIUAL EIViPLACEB1ElYTifIE1fI0D
❑Aquifer Test `i'i` ;IQ i ❑SkomwatcrDrainage • ft.r,��,.,,;.❑Experimental Technology ❑Subsidence Control ft.❑Geolhennal(Closed Loop) ❑TracerING LOG nttach additional sheets if neccssn❑Geothermal(Fleating/Coo ling Retum) .❑Other(ex lain under#21 Remarks TO DESCRIPTION color,hardness,soil/rock) e, ruin size ctc.tr. 0 4.DateWell(s)Completed: 1�'�1'ZZ Well ID# r� ft. C,16-
Y �..
Sa.Well Location: 1+ tt. o ft, r4 �� _ z^
i
12��1' U�Fr�sy Cyr i' li.i t„ �ii it. Jim
ft. �"'L/
O
Facility/Owner Name Facility IDII(if applicable) ft, ft. ^ r 023
9,701 �Gs nkl rA Oaks Wes/.'Z�It'-`yh Air; 0 760d rt. ft. Irifiz i�r..Y 'r�l n:t
Physical Address,City,aad Zip " i ;4U ft. ft. d IJ
k i(, (A 21.REMARKS
County � Parcel Identification No.(PM) Used hardened Steel drive Shoe.
5b.Latitude and longitude in degrees/minutes%seconds or decimal degrees:
(if well field,one latb lau is sufficient) i I. ; I`I
) r�I ' I'• 22.Ccrtificafi
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature ofCcrtified Well Contractor Date
AT signing this form,I hereby certify that tha,well(s)was(were)constructed in accordance+rith
7.Is this a repair to an existing well: ❑Yes or MNo /SA NCAC 01C.0100 or 15A NCAC 01C.000 if'ell Construction Standards and that a copy
if/Ills is a repair,fill out known ivell consiniction it fortnallan and explain the natlrre of the of this record has beer provided io the melt ou firer.
repair raider#21 remarks section at-on the back of dds',%oriii.
/ , 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:+ wN1!:.liil.i.
r ,
24.SUBMITTAL INSTRUCTIONS
9.'I'olal well depth below land surface: ,-6#5 (ft)
For urrrhiple a ells ltsr all dept/rs jdr'(ferent(ei Wnp1a--3 a 100:and 1Q100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of_c>tsing: (� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If hater/evel is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I L 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 '
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Oven-Loop Geothermal Return Welts Copy to the
county environmental health department of the county where installed
ItOR WATER SUPPLY WELLS ONLYe"' ;' "" 24d.For Water Wells producine over 100 000 GPD•Copy to DWR,CCPCUn
13a.Yield(gpm) Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Ib,
Fours GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-201".