GW1-2023-00950_Well Construction - GW1_20230120

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1 WELL CONSTRUCTION RE'CO CORD(GW-1) For Infernal Use Ouly:
1.Well Contractor Information: r,
Landon Phillips 14,WATER ZONES
Krell Contractor Nnme FROM TO DESCRIPTION -
'I 3441 A '01 .+ r "
ff. ft. ., 15
NC Well Contractor Certification Number 15.NW Poole Well and Pump Company ]FROMOUTERcTO formulll-casedwclls OR LINER ffnt licabic
FR0111 7'U UTAhIETEIi TIIICICNESS alAl'ERIAL
Company Namo { l ft. y f6 Cy tn. L?
16.ANNER CASING OR TUBING cotherntnl closed-loon)
2.WCII CDi15fYllellml PCrltlit#: 1 -(� ���� - pZ MON To DIAMETER I THICKNESS MATERIAL
List all applicable shell construction perndts(i.c.UIC,County,Stale,Irariance,etc.) ft. ff. in.
3.Well Use(cheep well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL `
❑Agricltlltlral ❑lvfut' al/Public rt. ft. iit,
❑Geothermal(hlealing/Cooling Supply) esidential Water Supply(single) ft ft In
❑Industrial/Commercial - ❑Rcsidential Water Supply(shared) 18.GROUT
❑Irri alion ❑Wells>100,000GPD FROM I TO MATERIAL EaIPLACEMENTAIETH00&AMOUNT
Non-1lralcr Supply Well: O r. U
❑Monitoring ❑Recovery ft. ft.
In•jcclion Well:
❑Aqu fifer Recharge ❑Groundwater Remediation
❑At uifer Storage and Recovery ❑Salinil Barrier 19.SAND/GRAVEL PACK If n licable
g ry Y FROM TO MATERIAL I EMPLACEDIENTdnETHOD
❑Aquilcr'I'cst ❑Stornwater Drainage ft. ft.
DExperimenlal•Technology ❑Subsidence Control ft. ff.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TU DESCRIPTION color,hardness soll/ruck type, rain sit etc.
❑Geolhennal(Heating/Cooling Return) 001her(explain under#21 Remarks) G fI it
4.Dale Well(s)Completed: Zell ID# tt. fL
C14Sa.Well Location: ft. C� �
I ft. ft.
1 Facility/Owner Name Facility ID#(ifopplicable) ft.
,Q �� j7�
_0-b—n'o - .�n��d rA �ns(t`�(C .jF1t I I'1� It. fl.IL ft.
Physical Address,Cily,laid Zip '
I Nei(Ice21.ItEb1ARiGS r
County Parcel Identification No.(PIN)
5b.Latitude anti longitude in degrees/my mutes/seconds or decimal degrees:
(ifwoll field,one Indlong is sufficient) 22.Certtficat'
il'
- Q17� O N �9e Ols�� w
6:Is(nre)the well(s): INPerumnent or ❑Temporary Signature ofCenifled Well Contractor ` Date
lit,signing this forin,I hereby certify that the u,efl(s)n•as(were)constructed in accordance mith
7.Is this a repair to in existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mich'Canstmetion Standards and that a copy
/f 7his is a repair,fill an!/arou n u el!consn uclion infnrnration and explain the nalta-e of the ofihis record has been provided to dre trell corner.
repair under 11121 remarks seclion at,on[lie back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having tine same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
/ 24.SUBMITTAL INSTRUCTIONSdep 9,Toilll well depth llt land surface: CQ U (ft.) Submit this GW-1 within 30 days of well completion per tine following:
For ruulttpla yells list all depths jd�crent(example-3Q200'and 1Q/00')
oCcasin 24n- For All Wells: Original Corm to Division of Water Resources (DWI),
10.Static water level below top g: (�` (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!/•wafer Icrel is above easing,use"+"
11.Borehole dinmeter: (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction Inellwd: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.nuger,rolary,cable,direct push,etc.) comriy enviromnental 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
l 13a.field(gpm) Method of test Blow Permit Program,1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Cwolina Deprintenl of Euvironmenlal Quality-Division of Water Resources Revised 6-6-20IS
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