GW1--03084_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name rROM I TO I DESCRIPTION
3441A S- ft. /0 6
tt. a�a ft.
NC Well Contmctor Certification Number )
15.OUTER CASING for multi case ellssOR LINER if o licnblc
NW Poole Well and PUMP Company FROM To DIAMETER THICKNESS MATERIAL
Company Name •i,I n- &3 ft. 6a in.' O /r
16.INNER CASING OR TUBING cathermA clo3cdAnn C
2.Well Construction Permit#: U/Z z (�i `� FROM I TO D1Ai1 MR THICKNESS MATERIAL
List all applicable well constnrerlon perin0s(l.e.UIC�Cbrinty,Stare,Variance,etc.) ft. ft. im
3.Well Use(ehecic well use): ft. [t. in.
Water Supply Well: 17:SCREEN.
rROM TO DIAMETER SLOTSIZE TIDCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft.
❑Geolhennal(Healing/Cooling Supply) esidential Water Supply(single) ft. fr. ;n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
❑Irri ation ❑Wells>100,000 GPD rROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt.
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery rR SAND/GRAVEL PACK if a Iicable
q g ry ❑Salinity Barrier rRonl To MnrElunL EMPLACEMENT METHOD
❑AquiferTcst j' ' ;'❑StotmwatcrDrainage rr. ft.
❑Experimental Technology ❑Subsidence Control
'. .';"
r
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG nttacIt additional sheets if necessary)
❑Geothermal(Hcafing/Cooling Return) 00ther(explain under#21 Remarks) rROM TO DESCRIPTION color,hardness,seu/roekt e, rnht size,etc.)
ft.
ft.
4.Date Well(s)Completed: r��'LZ Well ID# ft. ft.
.•.
5%Well Locations ;;;, iL ft. C-.tL.J
1,5✓..I� �rir�. �1�S �'
Faci81/OmicrNamc ' ft. ft.
• Facility ID/1
ft. ft. un;.
CAA
AD QG
Physical Address,City,and Zip " t ft. rt.
21.REMARKS
County Parcel Identification No.(PM) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/se'conds or decimal degrees:
(ihvcll field,one lat/loug is sufficient) 22.Certificflti
G.Is(arc)the well(s): ❑Permanent or ❑Temporary Signature o£Ccrtified Well Contractor Date
` By signing this form,/hereby certify that the.a'ell(s)was(mere)co-isrrneted in accordance idth
7.Is this a repair to an existing well: ❑Yes or­ i9No MA NCAC 02C.0100 or 15A NCAC 02C.0100 IVe/1 Cotistritciion Stnudardr and that a copy
If tins is a repair,fill out know it well catrsrntctiott iitfora-alian and explain the nature of Ire of this record has been provided to the well ouvrer.
repair under#21 remarks section or on the back of dds fornC"
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geotller mat iWells having die same You may use the back of this page to provide additional well constriction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:r I.1.:Y-Io n.•.
24.SUBMITTAL INSTRUCTIONS
9.'1'olnl well depth below land surface:
Far;naniple wells hrr all depths(fdperent(example-J rt 200.'a {t nd 2©100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ). r r (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If trater level is above caring,rise"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Borehole din meter: 6 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary ;" .:
24c.For Water Supply and Oven-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i FOR WATER SUPPLY WELLS ONLY:`
24d.For Water Wells producing over 100,000 GPD•Copy to DWR,CCPCUi`.
13a.Yield(gP m) Method 3 of test:
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: HTH o Amunt: 1 lb.
Form GW-I I North,Carolina Department oflinvironmenlal Quality-Division of Water Resources Revised 6-6-2018