GW1--03104_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 FRO51 TO DESCRIPTION
3441 A 70 rL az 5—
NC Well ConuactorCerti6calian Number '
15.OUTER CASING for multi-cased wells)OR LINER if n lienble
NW Poole Well and PUMP Company ]FROM TO DIAMETER TIHCKNESs MATERIAL
Company Name 1'r ft. Z i ft. in. ,0?
/' 16.INNER CASING OR TUBING(geothermal closed-loo l.�
2.Well Construction Permit tl: �� '(� FROM TO D1A11TMR THICKNESS MATERIAL
List all applicable well construction pennus(i.e.UiC,County,State,variance,etc.) ft. ft. in
3.Well Use(ellech well use). ft. ft. in.
Winter Supply Well: 17:SCREEN.
❑Agricultural PROM TO DIAbIEPER SLOTSILE TITICIOYESS MATERIAL
❑MunicipaVf ublic ft ft. in,
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single)
6 ft. ft.
❑Industrial/Commercial in.
❑Residential Water Supply(shared)
❑Jrri ation 18.GROUT
Non-Water Supply Well:
❑Wells>100,00o GPD FROM TO . MATERIAL EMPLACEMENT NIEI7I101)&AMOUNT
❑M ft.
❑Recovery tt
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ifa livable
❑Aquifer Test ':.pStomitvaterDrainagc FROM ft. TO ft. MATERIAL ENIPLACE51ENTMEfHOD
❑Experimental Technology ❑S,ubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach ndditionnl sheets if neccssa
❑Geothermal(Healing/Cooling Return) . ❑Other(explain under#21 Remarks) GRont TO DESCRIPTION eotor, inrdncas,soil/roch n c, ruin size,etc.
ft. ft.
4.Date Well(s)Completed: -��ZZ Well IDN ft. ft.
5a.Well Location: ;- ft. ft. ; Z
WG IlLCc ft.
pa//c''ility/Ownc/rName racility IDIf(if applicable) ft• ft.
11� /1//51 C//C 't JY` b//7/%�'�(�{✓ ft. ft. tfG1Yl1?.:�
Physical Address,Cit and Zip '; II% ft. f4 Q s i�f.•�r P}
�J I I cI
T ,Q,1(Gf/1 K 21.REMARKS
Colutty Parcel Identification No.(PiN) Used hardened steel drive shoe.
Sb.Latitude and longitude iR degrees/minutes%seedrids or decimal degrees:
(ifwcll field,ono lailloug is sufcicnl) .
22.Certifjcati
,.l �I Zi O N _��T1! � �LL W /
6.Is(ari:)('he,well(s): ❑Permanent or ❑Temporary Signature,ofCcrliliicd Well Contractor Date
I''"'r 1' ily signing this form,!hereby certify that iho,irell(s)was(here)constructed in accordance frith
7.Is this a repair to an existing well: ❑Ycs •or 'MNo 15ANGIC 02C.0100 or ISA NCAC 02C.0200 lfreli Colistntcliotr Srrnularrlr and illai a copt
jilds•tr a repair,Jill out knoirn well coesinictlon itrfor11,1101 aird explain Ire rratrve ojthe ujrhls record has Geen provided to the a e/!owner
repair corder IF21 reumrks section or on the Lack of thli jorrir:
I�allii 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop GeothermnI.I)Vells 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 Ovee in Remarks Box).You may also attach additional pages ifnecessary.
drilled:+
1"t 1,30 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
pornru%iiple wells list alldepdrs ijdd aa
erent(exrplc-B@200''gnd2Ql00') Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water level below top of.casing:'_ d'; ,p (ft) 24a. Tor All Wells: Original form to Division of Water Resources (DWR),
if+rater level Is above caring,use' F^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 -'(in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
RotaryProgram,1636 MSC,Raleigh,NC 27699'1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Sunply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:'
24d.For Water Wells producing over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpin) MctltDd of test: BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount:
;.(
Porn GW-1 ;North Carolina Department oflinvironmental Quality-Division of Water Resources
Revised 6-6
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