GW1--05519_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD (GW-1) For.Internal Use Only: --'-'
j
1.Well Contractor Information: i
Landon Phillips 14.WATER ZONES • f
Well Contractor Name FROM TO DESCRIPTION VI
3441A d30 ft. 02
3.5 ft. iyprk -I
ft. ft. I
NC Well Contractor Certification Number
15.OUTER CASING(for multi-casedlwells)OR LINER(if ap licatile)
NW Poole Well and Pump Company FROM TO ' DIAMETER THICKNESS MATERIAL _
�.3 ft. f /�7 3 ft. / f in. .�! 5/,(t AEG _
Company Name `
16.INNER CASING OR TUBING(geothermal closed-loop) • • •
2.Well Construction Permit#: kW r OlIc163-0022 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. R. in.
Water Supply'Well: • 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in. I
OGeothennal(Heating/Cooling Supply) xtesidential Water Supply(single) ft. ft. in. . "•�
❑Industrial/Commercial ❑Residential Water Supply pp y(shared) I8,GROUT
❑Irrigation . ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. dael ft, okf fiy fD Jp 2
❑Monitoring ❑Recovery ft. ft. -'I
Injection Well: -
ft. ft.
❑Aquifer Recharge DGroundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinit Barrier19.SAND/GRAVEL PACK(if applicable)
y FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test DStonnwatcr-Drainage ft. ft.
❑Experimental Technology • ❑Subsidence Control ft. ft. ----I
DGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,h�rdness,soil/rock type,Brain size,etc.)
ft. 2 ft. 761 DSO r
4.Date Wells)Completed: 3-15-2 3 Well ID# -'a ft. 1 l / ft. Ch Vt
q l J
5a.Well Location: f ft. 1,3 ft. /',2ni kt�
la P4-0/l 60011 941`/ ll ft. fa l/7 i• NR('f'r f
Facility/Owner Name�1 Facility IDII(if applicable) ft. ft. ""�a �Y trzi„
61 70 ! 14.A!L/:1 d�'t,,S tAkt t 124►k i'A dL ft. ft. AU 2 J� 2423
T
'-( Physical Address,City,and Zip a 7/,o 6/ ft. ft, :i 1� � r,r
11- I •
A)C Ice 6 21.REMARKS Dkajct �:.
Used hardened steel drive shoe.County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • �
(if well
�field,one laaU/Ions is sufficient) �j 2 22.Certiliicati
25.11A(DO . N 10.�� J�J W �
6.Is(are)the well(s): ❑Permanent or OTemporary -
Signature of Certified Well Contractor • Date ,
By signing this form,I hereby cent that the ire/I(s)seas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No 15.4 NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a c:.
If this is a repair,fill out known well construction h forivation and explain the nature of the of this record has been provided to the well owner
repair under 1121 remarks section or as 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 ir,t
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You nay also attach additional pages if necessary.
drilled:1
24.SUBMITTAL INSTRUCTIONS : •
P 3yS ft
9.1'otal well depth below land surface:
For multiple wells list all depths(fdtfjerent(example-3 n 200'and 2(3a 100') ( ) Submit this GW-I within 30 days of well completion per the following: .
10.Static water level below top of casing: 02 0 (it) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information ProcessingUnit,1617 MSC,Raleigh,
If water level is above casing,use"+" NC 27699-1617
24b.For Infection Wells:Copy to DWR, Underground Injection Control(IUC';17.Borehole diameter: 6 (in.)
Program,1636 MSC,Raleigh,NC 27699-1'636
12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to tth
(i.e.auger,rotary,cable,direct plash,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:
5 BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
i
13b.Disinfection type: HTH Amount: 1 lb.
Four GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 G