GW1--03094_Well Construction - GW1_20230428

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATERZONES
Well Contractor Name FROM I TO DESCRIPTION
3441 A G ti, ' IT-6 fa 3 !
NC Well Contractor Certification Number
2 qO ft LI
15.OUTER CASING for multi-cased' ells PUMP
if n n blc
NW Poole Well and Pump Company FROM TO DMWrER THHCKNESS ntnTERIAL
Company Name in. U Z 5— / (V
_ 16:INNER CASING OR TUBINGvf(geothermal clo3ed-loo C
2.Well Construction Permit 4: � S FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction pernnits(i.e.UIC,,County,State,Varlance;etc) ft. ft is
3.Well Use(clieckwell use): ft. m in.
Water Supply Well: :19 SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. in.
❑htdustrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL rrurLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G tt. a a`
❑1vlonitoring ❑Recovery fL ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salini Barrier SAND/GRAVEL PACK ifa licable
tY FROM TO MATERIAL EMPLACE51ENT METHOD
❑Aquifer Test O3fotnwater Drainage FL
„s.;!•
❑Experimental Technology .! OSubsidence Control ft. %
❑Geotllenmal(Closed Loop) ❑Tracer 10.DRILLING.LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) FROM To DESCRIPTIONcolor,hardum,soil/rock type, nin size,etc.
ft. ft.
4.Date Well(s)Completed: Well Wit ft. fa _ e, a
5a.W(ell Location: ft. ft. ;�� „ —
ft. ft. e
Facility/Owner Name' !"Facility ID#(ifapplicable) ft. ft.
7 G �� ft. ft. 10{titiri:, .'•Ls:l r;",U r
' ft. ft.
Physical Address,City,and Zip � � '""";' `I,' �;(^,I !,�;
�7�Cryt y
21.REMARKS
County rl Parcel Identification No.(PM) Used hardened steel drive shoe.
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/Jong is sutlicient) ;i!I !:>.• 22.Certificati
�( oa� �cJ� N ��� �olg2 W
6.Is(ar6)the well(,'): 01'ermanent or ❑Temporary Signature ofCcrtifred Well Contractor Date
I;!'.C:; by signing this foron,l hereby certify that dre,rvell(s)mas(irere)constructed in accordance with
7.Is this a repair to an existing well: ❑Ytsi-l'or' InNo 13A NCAC 01C.0100 or 154 NCAC 01C.0100 Iirell Construction Standards and that a copy
If this is d repair,fill out known well constructiou hrfonrrpN9tr and explain the nature ojthe of tlds record has beenprovided to the irell owner.
repair under 1i11 reinarks section or on the.back of this(form.
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-1 is needed. Indicate'TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:+
24.SUBMITTAL INSTRUCTIONS
9.'Cotal well depth below land surface: P fL
eIan pie=3 rt 200'and 1®!00') ( ) Submit this GW-1 within 30 days of well completion per the following:
ror multiple ivel/s Itst all depths trdoeieni(
24a. For All Wells: Original form to Division of Water Resources (D1VR),
fu Static water level below top of,casing: !i`: ZG (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ljwaier level Is above casing,use"+" g g ,
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: Rotary '-
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to site
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS OPTLYi• 24d.For Water Wells producine over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test.
BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
136.Disinfection type: HTH Amount-
1 Ib.
Fonn GW-1 ,North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018