GW1-2023-00948_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
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1.Well Contractor Information: y�t
Landon Phillips
p 14,1VATER ZONES �O J
FROM TO DESCRIPTION
I \VcIICoulrncicrNnmo ft.
j 3441 A
i
ft. ft.
NC Well Coulraclor Certification Number 15,OUTER CASING for multi-cased wells OR LlifEit if n i licable)
I NW Poole Well and Pump Company Mort To UTAh1ETEIt TI11C1{NESS alA7'ERIAL
f6 fL in,
Company Nanic
�77��q �� 16.INNER CASING OR TUBING t
Well
closed-loop)
2. ell Construction Perinit>7: I D(A• — 7 Mont To DIAMETER THICKNESS MATERIAL
list all applicable well coarn-uclion pe"nits P.C.U1C,Caotty,Sete,Maritime,Cie.) ft. ft. I.).
3,Well Use(check well use): ft. ft. in•
N\'ater Supply Well: 17.SCREEN
I t y FROM TO DIAb1ETER SLOTSI'LE TillCKNESS MATERIAL
!I! ❑Agricultural ❑Municipal/Public rt. it
n. i�t• ,fV G
1 ❑Geothermal(1-1caling/Cooling Supply) ❑Residential Water Supply(single) ft. fl, in. 72
❑industrial/Commercial ❑Rcsidcntial Water Supply(shared) 18.CROUT
'I ❑Irri ation ❑WelIs>100,000GPD 17HOM TO MATERIAL Ea1PL\CEMENI'NIET110D&AMOUNT
II Nou-WalerSupply Well: rt. ft.
j ❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEL PAC[{ if a i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E51PWCEIIIENT5IETII0D
❑Aquilbr'I'cst' ❑Stonn\vater Drainage lt. Cf
Clt3xperimenlal Technology ❑Subsidence Control
❑Geolhennal(Closed Loop) 01'racer 20.DRILLING LOG attach additional sheets If necessary)
FIton TO DESCRIPTION color,hardness suNrock type, rain size etc.
II ❑Geothermal(Heating/Cooling Return) 00lher(explain under H21 Remarks) 5. ft —G•-
4.Dale Well(s)Completed: � —Owell IDH
5a.Well Location:
�l n ft.
Ut��- fC 0?&,yFv(u)) ft.
Fncilily/Owner Naanic 7 Facility IDb(if applicable) ft. ft.
I n c
(7- h L o� @ �.... . rf. ft.
Physical Address,City,and Zip d�SO 7 ft. ft.
r A rL 21.RE MARKS t
County h Parcel Identification No.(PiN)
I 5b.Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one Intlioong is sufficient) 22.Cerlifleat' �-
W
f 6.ls(are)the well(s): 01'ertnauent or ❑Temporary Signature ofCcnifidd Well Contractor ` Datc
By signbtg this farin,I hereby certify ilia!ilia well(v)tras(were)constructed in accordance truth
7.Is this a repair to all existing well: ❑1 es or IJNo 15A NCAC 02C.0100 or iSA NCiIC 02C.0200 well Construction Smndnrrtr old that a copy
I !f ihis is a repair,fill out knoirn irc/l construction information and explain ilia nature of the aflhis record has been provleted to the irell owner.
j repair under 1121 remarks section oi•on die back of this foral.
23.Site diagram or additional well details:
may [lie back of this page to provide additional well construction info
You
3.For CcoprobdDPT or Closed-Loop Geothermal Wells having the same y use a
construction,only I GWA is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (fl.)
! lror amhiple wells list all depths Ifd�ereni(exaniple-3@200'aind 2 rr l0o') Submit this GW-1 within 3U days or welt completion per the following:
1 U.Static avatar level below top of casing ) 24% For All Wells: Original fora to Division of Water Resources (DWR),
1 tinier level it above el belng,use o •• 5- (ft' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
C 11.Borehole diameter: (in.) 24b.For Injection Wells.,Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Ralcigit,NC 27699-1636
•12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
{ (i.e.miger,rotary,cable,direct push,etc.) county envirotuneutal health department of the county where mslalled
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rotiucin over lU0 OOU GI'D. Copy to DWR,CCPCUA
BIOW Permit Program,l61 I MSC,Ra etgh,NC 27699-161 I
13a.Yield(gpnl) j Method of test:
HTH 1 lb.
13b.Disinfection type. Amount:
Forth G\U-I North Carolina Department of Enviroumenlal Qunlity-Division of Water Resources Revised 6-6-2018
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