GW1--05497_Well Construction - GW1_20230825

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: —ft
1.Well Contractor Information: • !
Landon Phillips •14::WATERZONES...! I �.
-.p, I -
Well Contractor Name FROM TO DESCRIPTION •
3441A J Jft. (�5 ft. (aj9fl1/1
ft. ft. I NC Well Contractor Certification Number _
w
15.OUTER CASING(for.multi-casedells)OR LINER(if ap licatile) _
NW Poole Well and Pump Company FROM TO DIAMETER I THICKNESS MATERIAL
Company Name -1-1 ft `�I D. / f in // `G'ph i d (t
,^ - 1 16.:1NNER CASING OR TUBINGb(geothernial closed-lop) •J
2.Well Construction Permit#: 15 IN-- 0,5+ - Z O 2( FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ' in. -
3.Well Use(check well use): ft. ft.
Water Supply Well: 11-SCREEN ' - .i.-!
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential 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: 0 ft. 1,.,�J ft. Aok( I) PC7J t�
:Monitoring . ❑Recovery ft. (J ft. •
Injection Well: u-
ft. ft. .
❑Aquifer Recharge ❑Groundwater Remediation
.19:5AND/GRAVEL.PACK(if applicable)'
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG(attach additional'sheets if necessary). '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrocktype grain size,etc.)
ft. ft. '
iZ7,� SrJt (..:.
4.Date Well(s)Completed: 1—'0-2$ Well ID# A ft. 116 ft. Gi<.y
5a.Well Location: cf( ft. 76 S ft. j(-,,f'11e--L- . —
!. N I::LI:i V 17_,
Facility/Owner Name Facility ID#(if applicable) ft. ft. .
67313 fl2e 0 (2c.-1 P_&lert/l ,O a 761_3 ft. ft. c
Physical Address,City,and Zip ft. ft . . - 1fliefPRal:fy n Pr :1441'e, V a
C�IL� 21.REMARKS. ),jtJ�'of+jr
County V v -:Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -_1
(if wellfield,onene latllonng is sufficient) 22.Certifrcati
el
✓. IIT/at t �� �f! N .���� !/ W
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6.Is(are)the well(s): Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l No 15.4 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on Are 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 iprovide 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 necessar.
drilled:I ' 24.SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: �v/5 (ft) per Submit this GW-1 within 30 days of well completionthe following:For multiple wells list all depths((different(example-3t}00'and 2@100') Y P
624a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information ProcessingUnit,1617 MSC,Raleigh,
If water level is above casing,use"+" i g ,NC 27699-1617
11.Borehole diameter: 6 24b.For Injection Wells: Copyto D UndergroundInjection (TUC)
(in.)
WR, Control TUC'
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary 1 '
12.Well construction method:
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,CCPCUA
13a.Yield(gpm) `
Method of test; BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I 6