GW1--05500_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD(GW-i) For Internal Use Only: I ---,i
1.Well Contractor Information:
Landon Phillips .
Well Contractor Name FRO ATER ZONES DESCRIPTION _,
3441 A G'SD it (oss ft• 2 I I
•
ft. ft. { I
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)'OR LINER(if op licable) .
NW Poole Well and Pump Company FROM TODIAMETER' THICKNESS MATERIAL
ft ft. n
Company Name •
16.INNER CASING OR TUBING'(geothernial closed-loop).
2.Well Construction Permit#: t/'7 V -- O qq 7 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counts,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft.' " ' ' M.
Water Supply Well: 17.SCREEN . " 1 i.it
FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural •❑MunicipaVPublic ft. ft. in.
OGeothennal(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 Veil: • ft. ft.
. OMonitoring DRecovery ft. ft'
Injection Well:
ft. ft
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ' ' MATERIAL , EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. .
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING.LOG(attach additional sheets if necessary) '
OGeothermal(Heating/Cooling Return), ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ete.l
L 0s-ft. 7 oc fa' -
I �7rG,nr1e
4.Date Well(s)Completed: /`16`2 3 Well ID# -- ft. ft. �-.
5a,Well Location: / // ft. ft. F ,E C E I t�E r-.
Veill2 011tT6(Ke— ft. ft ! AUGno 1
Facility/Owner Name Facility ID#(if applicable) ft. ft. !} ZOZJ
/O o t sl,r -ks fZG/ /26./ jA A C L 1(CI T ft. ft: ' InfortrAtm Prr,.^.mvai?,u
Physical Address,City,and Zip
ft. ft. l�trvtnt6l�Lti
(,-)Gl IC e 21.REMARKS).. ' .. • ,
Used hardened steel drive shoe.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one ladl`onng is sufficient) (�, /�,Q, t�� 22.Certificati i.:
5.-l21/ Z N 7U• � I c64-ca W - - /-/7-0,3
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0'200 Well Construction Standards and that a copy
Ijthls is a repair,fill out known well constructioninformation 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: 7 0 s ft
For multiple wells list all depths ifdijjerent(example-3(a�2c )000'and 2®LOOS) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: U ft 24a. For All Wells: Original form to
J Division of Water Resources (DWR),
ljtivorer level is 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(IU(:)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary I
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 over100,000 GPD:Copy to DWR,CCPCU_`.
13a.Yield(gpm) Method of test:
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 lb. i
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 E
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