GW1-2023-00952_Well Construction - GW1_20230120

l
1 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �� �
Landon Phillips r'A
i 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A `�� rL 1 � ft. 7 G A, `y�a:;v (2
NC Well Contractor Certification Number ft.�g "S ft- 3
15:OUTER CASING for mrilti-cased wells OR LINER if a licable �,�
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
i Company Name t 11 ft. �S"Q ft. eP- in. 6,4L;l
i� � r�j1]pr r�/� 16.INNER CASING OR.TUBING v(geothermal closed-loo
iII 2.Well Construction Permit# 1 f: .jJ 07 OJ— �0 90, FROM TO DIAMETER THICKNESS MATERIAL
l ivt all applicable irell construction pennr�ts(i.e.UIC,Counly,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
jWater Supply Well: 17.SCREEN
i FRO51 TO DIAMETER SLOT SIZE THICKNESS AIATEILIA
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ,(Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
i ❑i ri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1 Nou-Water Supply Well: 0 B. a0 ft. 13f�,tTo.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EN PLACEMENTMETIIOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets if necessary)
FROai .TO DESCRIPTION color,hardness,soillrock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 tt. ft. L
�¢ "-o 0
4.Date Well(s)Completed: S` �O'(� VS'eI11D# o� ft. /f t ft.
5a.NellLocation: �l ft dS0 it fZPV' t Q'u,,/=IZ
1 f
L 9A9eT/� "APRA L�S �� ft. SOS IL 6 ,T_
Facility/Owner Name Facility IDS(ifapphcable) ft. ft.
TIN Ro/t L) ft. ft.
Physical Address,City,and Zip ft. ft.
/ -^f�k 21:REDIARKS
County Parcel Identification No.(PIN)
1 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/]on',is sufficient) 22.Cer Hill caIt
W y/a%fay
6.Is(are)the well(s): ®Permanent or []Temporary Signature of Certified Well Contractor Date
Bysigning this form ehereby certify that the u•el/(s)"'as 6vere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 iVell Consiniction Standards and that a copy
lftris is a repair,fill out kno,ru bell construction Information and explain the nature of the ofthis record eras beenprovided to the ivell osier.
repair under t121 reutarks section or on the back of this form.
23.Site diagram or additional well details:
S.Foe-Geoprobe/DPT or Closed-Loop Geothermal Wells leaving 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: 1 _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 563.S (ft.)
For unrhiple hells list all depths ifdfferent(example-3 a200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: 0 (ft)
. 24a. For All Wells: Original form to Division of Water Resources (DWR),
1ju•nler Jerel is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
� H.Borehole diameter: (in.)
24b.For Injection Wells:Copy to DWR Underground Injection Control(TUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
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) 16 Method of test: Blow Permit Program,16I I IviSC,Raleigh,NC 27699-1611
II 13b.Disinfection type: HTH Amount: 1 lb.
j Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
II