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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1 1
1.Well Contractor Information: ?
t
' i
Landon Phillips •14.WATER ZONES...:..• '
Wgll Contractor Name FROM TO DESCRIPTION
3441 A 0 7o ft. )75 ft. /Q J) 1?
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for amid-cased"wells)OR LINER(if ap licable) ;
NW Poole Well and Pump Company FROM TO DIA/METERrI TLHYCrciESS MATERIAL
Company Name '4- ft 14. f6 (, • f
O u, tu,2cd
16.'INNER,CASING OR TUBING•(geo .rthermal closed-loop)`
2.Well Construction Permit#: SSa y • FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft. ft. in.
3.IWell Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROMfL TO ft. DIAMETER SLOT SIZE THICKNESS MATERIAL❑Agriculhtral OMunicipal/Public
in.
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) ft, ft. in.
fl
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: Q �
ft. ft.
❑Monitoring ❑Recovery ft. G ft. ��rY�/7 �(I J�
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation fr. ft
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft. •I! . -`
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer •20.DRILLING.LOG(attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under ii21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
c ft. a ft. "TO p ,'
4.Date Well(s)Completed: a- 1-'-3 Well ID!) .a, ft. `jam ft. ,74- X .
Sa.WellLocation: , 5ft. 3G� s t. G,il�; ,ram
r
J
Facility(//Owner Name FacilitylI !Di/(if applicable)/ ft• ft• �j r
L-)A ' Gillt r(Y L"( Ch(--A-- I /7rre-( Alt_ ,c /5/1 ft. fL f���] fe A t�L�
Physical Address,City,and Zip ft ft Inkroraticn Prmaaorig Un./
C h C.- l n l C01 '21.REMARKS • .toia(G
County Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell field,one lat/long is sufficient) 22.CCrti[icati
5. e ( 19 N79 . 151 -JCL W 2 _ I- Z3
Signature of Certified Well Contractor Date
6, s(are)the well(s): OPermanent or ❑Temporary _
By signing this form,I hereby certify that the well(s)was(were)constructed In accordance with
7. s this a repair to an existing well: ❑Yes or 15No ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and thai a cane
If This is a repair,fill out known well constntctlon information and explain the nature of the 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:
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 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
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 05ft
For multiple wells list all depths ifdifferent(example-3 a 00'and2@lOO') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: e52 G ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijtraterleve!!s above casing,use"+" ( ) 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)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
(i.e.auger,rotary,cable,direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to tiro
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) Method of test:
BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
it
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 1 8