GW1--03107_Well Construction - GW1_20230428

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO I DFSCRIVrION
3441 A cq,7 p ft. 75 17PA
NC Well ConuaclorCertificntion Number '
6 6 rt. fr. 1`I elk
15,OUTER CASING for multi-cased wells OR LINER if n licnble
NW Poole Well and Pump CompanyoM TO DInntETER TIIICRNESS nATERIAL
1 f4 ft. in. c i
Catupany Nmnc t if(�r/
C��—7 C 16•INNER CASING OR TUBING cothcrmal cla r3ed-loo
2.Well Construction Permit#: Q / ) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnrcitor pernrlts(i.e.UIC,County,State,Varta)ide,etc.) ft. ft. in.
3.Well Use(clrecit well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
❑A ricultural l FROM TO DIAMETER SLOTSI'LE TH1CKNESS MATERIAL
g ❑Municipal/I ublic tt. ft. in.
❑Geothermal(Healing/Cooling Supply) Residential Water Supply(single)
in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
oMft.
❑Irri ation ❑Wells> 100,000GPD MATERIAL EMPLACEMENT ME:1HOD&AMOUNT
Non-Water Supply Well: O❑Monitoring ❑Recovery la
Lnjection Well:❑Aquife'rRecharge ❑GroundwaterRcmcdialion
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK irn licnble
. TO MATERIAL EnPLACEnENTfETIOD❑AquifcrTcst i FROM
a ft•rmv ft.
,.,.. :.
OGxperimenlal Teclinblogy ❑Subsidence Control ft. ft.
!,
❑GeOlhermal(Closed LOOP) ❑Tracer 20.DRILLING LOG attach additional sheets ifneccssa
❑Geothermal(Plealing/Cooling Retum). . ❑Other(explain under 921 Remarks) Fmonl TO DESCItIPCION carat•,knrdneae.soil/rock t c. rain rice,etc.
p ft. ft. �D�/L
4.Date Well(s)Completed: �t�—o�/-Z 2 Well IDII ft• s ft. C
5a.Well Location:
tt�Y j ; ;r SS ft. cJOS ft.
�ShTon 1 '>l�'-th !"'I�' i,;;i,:, ft. ft• -'�'�`� �.�f
facility/Orvncr Name' Pucility ID#(if applicable) ft. ft. APR 2 b 207.
,$5 5cy{)lin�:-�d:ue S� 335'1zi• e'7A Nz ��609 ft. ft.
Physical Address,City,and Zip ft. C4
c jj� •�r
����I(_il A•' 21.REMARI4S
County ` Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladloag is suflieicnQ 22.CcrtiGcati
N 9l,4641-15 W
G.Is(arc)the well(s): ❑I'ermnnent or ❑'1'empOrary Signature ofCcrtifrcd Well Contractor Date
By signing dds fornt,I hereby certify drat/ho p'all(s)u,as(were)constructed in accordance with
7.Is this a repair to an existing we'll: ❑Yes or [!)No 13A NCAC 02C.0100 or 15A NCAC 02C.0100]fret/Construction Standards and that a cnnr
YOU is a repair,fill out knorn well consnvictiaA hb`oranat(odn and explain the nature of the of dds record has been provided to ilia it-ell owtrer.
repair under 1121 remark section at-air die back of this foritt. '
t,il p 1, 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal-)yells having die 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 ofwclls (add'See Ove1 in Remarks Box).You may also attach additional pages ifnecessary.
drilled:+ r, i,!;;iil•a
24.SUBMITTAL INSTRUCTIONS
9.'foL•tl well depth below land surface: �OS (fL)
rot,unituPle wells list all depths lydicrent(ezantplc-3rr20010,':aird2©100') Submit this GW-I within 30 days ofwell completion per the following;
10.Static venter level below top of casing: p(6;,i: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f hater level is above casing,use-1.^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1L Borehole dlnmeter: 6 (in.) 24b.For Infection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
(i.e.auger,rotmy,cable,direct push,etc.) 24c.For Water Sunnlv and Onen-Loon Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
IrOR WATER SUPPLY WELLS ONLY:* 24d.For Water tgP ) methodof test:
Wells nroducinR over 100 000 GDI' Copy to DhlrR,CCPCU�.
13a.Yield m BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:
HTH 1 Ib
Amount:
fomt G1V-1 Northi Cnrolina Department ofEnvironmenlal Quality-Division of Wnter Resources i n lean r n-•rn If!