GW1--03074_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD QW-1) For Internal Use Only:
1.Well Contractor Information: j
Landon Phillips 14.WATER ZONES J
Well Contractor Name iROM TO DESCRH1rION
3441A
rt. rc.
NC Well Contractor Certification Number
15.OU.TER CASING for multi-cased wells OR LINER if n lieable
NW Poole Well and Pump Company I4!om TO DIAMETER TIIICKNESS MATERIAL
d
Cmmpaiy Name 1- ft. ft. in.' , 1 V ff_ 'r-Id"
/ GQ 16.INNER CASING OR TUBING(geothermal closed-Innn.
2.Well Construction Permit#: (T w'd 7 t1 V�'Z6Z.Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernits(i.e.UIC,Comity,Stare,Parlance,etc.) ft. rt. in.
3.Well Use(elleelr well use): ft. rt, in.
Water Supply Well: 17:SCREEN.
❑A rletlllnral FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
g ❑Municipal/Public ft. ft. in.
❑Geollienmal(Neating/Cooling Supply) -WResidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18..GROUT
❑Irri anon ❑Wells>1OQ000.GPD FROM TO MATERIAL EMPL CEMENTMErHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ft. ft.
Remediation 19..SAND/GRAVEL PACK ifa licable❑Aquifer Storage and Recovery ❑SalinityBatricr FR05I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ! ❑StorjnwaterDrainage f�• rr,
❑Experimental Technology ❑Subsidence Control tr. tt.
❑Geolltennal(Closed Loop) ❑Tracer 20.DRILLING.LOG attach additional sheets if necessary)
❑Geothermal(Beating/CoolingReturn) ❑Other.(ex lain under#21 Remarks) I4tt_ To DESCRIITION coto,tmrdne„soalrockt e, rain size,ctc.)
ft. '1 ft. P 6G5
4.Date Well(s)Completed: -Z ��2 Well ID# V ft• IcG ft.
5a,Well Location:' tt. ft.
UII ttln Co!/A�!1 ft.
Facility/Owner Name Facility ID#(ifapplirable) t+• ft. APO 2 s
2073
(17a I �_-Vc dd('A prr/�5.1 J 11`/ �� lie/A VC f\
Physical Address,City;and Zip ft. ft. �� � ''
C4,�(�t 21.REMARKS
Cowry Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutesJseconds or decimal degrees:
(irwell field,one Iat/long is sufficient) I f; il I' 22.Certilleati
3S• Sc� �b N ��:I li� 1-1 W
6.Is(nrb)the svell(s):'❑I'ermnnent or ❑Ttitnporary Signature ofCcrtified Well Contractor Dalc
Ilysigning this fora,I hereby certify that the.me/1(s)u•ar(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes `or 8No 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
/(dais Is a repair•fill out knovn mell construction iuforination,and explain the suture of the oft/ds record has been provided to the me//ovquu..
repair under#21 remarks secilon or air line back of thisilonn.
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 1 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;, ,,pt'.,
24.SUBMITTAL INSTRUCTIONS
6e.�
9.'I'olal well depth below land surface: (ft)
For nulriple mel/s 11st all depihs ifdIa'reiii(esntnp/e='3t?a,1,00. ud 2Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: :6 (ft) 249- For All Wells: Original form to Division of Water Resources (DWR),
/f mazer level is above carhig,use"i•^ 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
32.Well construction method: Rotary �'
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells•Copy to the
u .I county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GI'D•Copy to DWR,CCPCUA
13a.Yield(gP in) l -method of test., BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1 111
13b.Disinfection type: HTH Amount: 1 Ib
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water.Rcsourccs Revised 6-6•201 g