GW1--05430_Well Construction - GW1_20230821

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -
1.Well Contractor Information: i
Landon Phillips • - •
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441A TO R. f q ft. Lio
NC Well Contractor Certification Number
3,10 311r ft. d S'
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
1r ft Ieoq ft- 6, in.Company Name
/7/ ("/41✓ _
16.1NNER CASING OR TUBING(geothermal closed-loop) • •
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc.) ft. ft. in. -`I
3.Well Use(check well use): ft. ft, in.
Water�// Supply Well: 17.SCREEN . . . . , . •
7u riCUhural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
,�g ❑Municipal/Public ft. ft. in.
' ❑Geothennal(Heating/Cooling Supply) l lResidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) __
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. 2 6 ft.
%c l2m le Pei`-
^❑Monitoring ❑RecoverY R. tt.Injcetia Well:
-----
ft. ft.❑A uifer Recharge OGroundwater Remediation uifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
❑A
q g OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft. "•-•
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soitlrack type,grain size,etc.)
O ft. , ft. To,;, •�Ot
4.Date Well(s)Completed:/ -I 7' 2 ? Well ID# ft. ft.
Sa.Well Location: '5-0 ft• j iy ft. (- ru n i 1.e. R EC,E I P.V L. -
c :/'
to
ft. ft. 1---'‘ a
7 p...1 ..j tom) }-r '&4r„%I
w ((��H�1
Facility/Owner Name n / ,� Facility ID//(if applicable) ft. ft. AUIi "� �VLJ ��;
//,/3/ 17 fl1 /cG! 'Dade? ✓, ft. ft. in'
�rz'l.t cr ..I'til Pftl•C . �
Physical Address,City,and Zipft. ft. ►R+ 't" s t _
Y Y Dv.cl °'-'
.5 t�I �� 21.REMARKS ��
County / Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ ,
(if well field,one tat/long is sufficient) _ 22.CertiGCati
3s. 210DSSN --7g. 5 -g W • 2 _1�-Z3
6.IS(rtre)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor , �- Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to au existing well: ❑Yes or L°INo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a co:•i•
If this is a repair,fill out known well construction information and explain the nature oldie of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction in
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the samer construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:I
3 g' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 ft
Formultiple wells list all depths iifd�erent(example-3@200'and 2Q100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: / 7 U (ft) 24a• For All Wells: Original for to Division of Water Resources (MAT.),
If water level is above casing,use"+" I form to
Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR,Underground Injection Control(WC)l1.Borehole diameter: 6 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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,CCPCU_
13a.Yield(gpm) 6 5- Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 t: