GW1--03073_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
Landon Phillips 14:wnTER2011Es J
Well Contractor Name FROM TO DESCRIPTION
3441 A
10 tc. a d U
NC Well Contractor Certification Number
La
15.OU.TERCASING rormulti•cas Cvells OR LINER ffri licable
NW Poole Well and Pump Company moM TO DIA11IErER THICKNESS ItIATERW
tt rr. / in. 10 z T C� I V
Company Name 1 to
/ I ' .' 10.LINER CASING OR TUBING eothermal elated-loo
2.Well Construction Permit#:-( i1 l, t)7 9 Z S_ Z D L Z FROM TO D1ADt1TER THICKNESS MATERIAL
List all applicable well construction pern ills(i.e.UIC,County,Stare,Variance,etc.) % % in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.�SCREEN
PROM TO DUMIEfER SLOT SIZE TBICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geolllennal(Heating/Cooling Supply) L sidential Water Supply(single)
6 ft. ft. in.
❑Industrial/Commercial Residential Water Supply(shared)
18..GROUT
❑liri ation ❑Wells>100,000 GPD FROM TO MATERIAL Ef1IILACEarENTMEIHOD&AhIOUNT
Non-Water Supply Well: O fr. Z ft
a><0,:,(-( Ott i
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier i`'I%.SAND/GRAVEL PACK 1'a licable
FRODI TO MATERIAL EMPLACEMENT I1fETHOD
❑Aquifer Test , I l.,�Ir l + OStorniwater Drainage ft• fr.
❑Experimental Technology OSubsidence Control tr. ft.
❑Geothermal(Closed Loop) ❑Tracer :10:DRILLING.LOG attach.additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1
FROM TO DESCRIPTION color,hardness,soil/racktype,grain sicc,etc.
M Z ft.
4.Date Well(s)Completed: /"Z/-7 7_ Well ID# nREMARINCS
(�
Sa.Well Location: ;,Facility/Ow r NameFacility ID#(if applicable)/ 1,12P 4t ✓°e" /JiiS (.�/�-r,. Mn/'-1 Ctt /Physical Address,City,'and Zip 1':y., q I
County Parcel Identification No.(PIN) Used hardened steel drive'shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)r, ;i;,; qo i r ,. 22.Certificati
3S. MU Les
w f 7
6.Is(arc)the well(s): ❑Permanent or ❑'Temporary Signaturc ofCcrliticd Well Contractor Date
�'' ";"' By signing this form,l hereby certify chat the rve/l(s)was(here)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and drat a cony
If this is a repair,fill out known well construction ittforrlration and explain the nature of ilia of this record has been provided/a the well cirner.
repair rider#21 remarks section or on the back of this form.
I. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geother(nal iWells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:+
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'i
(ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if ddereni(eianrpI 3 00.'and 2Q100')
10.Static water level below top of casing: Z,ic, (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
I I.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: RotB'ry
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Suuply and ODen-Loon Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Droducft over 100 000 GPD' Copy to DWR,CCPCUA
13a.Yield(gpin) 2- 0 Method of test: BLOW Permit Program, 1611 MSC,Ralenigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 E