GW1-2023-01015_Well Construction - GW1_20230125

I,
WELL CONSTRUCTION RECORD(GW-1) ForInlemal Use Only:
1.Well Contractor Information:
Landon Phillips " b "
t t (Z`Y � ,a.�" 14,WATCRZONES C 1
_n
Well Contractor Name FROht TO I DUCRIMION
3441A JAN 2 5 2023 G rt. 10 G
NC Well CowmctmrCcnificatian Number I '
0 R. ; D. C "
miff;���'an, Pri?l;e9C3w�i rug UI� 15,OUTER CASING for multi-cnsed,_oils OR LINER if n Ilcablc
NW Poole Well and Pump uo`rrf)p, OG FROM TO DIAMETER TIIICICpN.ESS aIATERIALL/
Company Naatc
.S ft. AS ft. I In• ,aft ALlf,
16:INNER CASING OR TUBING cotkermnl closed-loon)
2.Well Construction Permit N: 7 fi / FROM TO DIAMETER I THICKNESS I MATERIAL
LAar rill opplicahle well construction permits 0.e.UIC,Coma)',State,Irarlance,etc.) ft. ft. in.
3.Well Use(cheep well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER ' SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. 30 R. [f in. q rO
❑Geothermal(I•Icating/Cooling.Supply) Residential Water Supply(single) rt. a. In.
❑industrial/Commercial - ❑ILcsidential Water Supply(shared) 19.GROUT
❑Irri nlion ❑Wells>100,000GPD FI(Oat TO MATERIAL EMPLACEMENT METHOD&AaIOUNT
Non-1\tntcr Supply Well: Q ilk ft. �owrf G
❑Monitoring ❑Recovery ft. ft. r !/
Injection IYCII:
'
❑Aquifer Recharge ❑Groundwater Remediation P. ft.
❑Ac uirer Slora a and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EatPLACEaIENTISIETHOD
❑Aquil'crTcst ❑StormwaterDrainage 0 ft. T [L o
❑Lxperimcnial Technology QSubsidence Control ft. / ft.
❑Geothermal(Closet!Loop) ❑Tracer 20.DRILLING LOG nifach additional slieets Irnecessn
Fit= TO DESCRI11 PION color,hardness solVrock type. ruin sin etc.
❑Geothennnl(1•leating/Cooling Return) .' []Other(explain under#21.Remarks) it. a fr.
�.
4,llalc Well(s)Completed:VV_42-4 Well IDN ft. ft.
5a.Well Location: ft. S' H. SAALOE
ko 1-: H. a.
Pncil'(y/Owner Name ra,cility IDN(ifapplicable) ft. ft.
-71 5- Poe &r< p Gs A ft. ft.
Physical)Address,City,and Zip `}' ft. ft. i
21.REMARKS �j t ( �-
County 'Parcci Identification No.(PIN) ~ HA R eCOF- J� F L
5b.Latitude and longitude in degrees/mhuites/seconds or decimal degrees: V
(irwell field,oiic Iavlong is sufficient)
J I O p N 1 :�S900'o 22.Certificat'
6.Js(nre)the well(s): IPPermnnent or dTgnipprary, Signature ofCertifncd Well Contractor ` Date'
B),signhrg llii.r form,/herehj•certlj•Ihar'the wall(i)ryas(were)cansrnrcred hi accordaice,t•lih
7.Is this a repair to an existing well: ❑Ycs,j or•i,8No 15A NCAC 02C,0100 or ISA NCAC 02C.0200 Well Caaanicuan Standards and that a cop),
1j'thir Is a repair,fill our knoirn Drell construcdoit L frivagoit and etrlaiu the nature of the of this record has been provided to the ire/l owner.
repair under 1121 remarks section a•of the hack of this form. i
t l� 0,1` 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geollicrllal Wells having the same You may use Elie back or this page'to provide additional well construction info
construction,only I OW-1 is needed. Indicate T0'TAL NUMBER or wells (add'Sce Over'ill Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS,
9.'I'otal well depth baton'land surface: 3, (ft.)
For ntultipk u•ellr list all depths ifd&ercnt(esaoiplc-3@a,200'and 2 n l00') Submit this GW-1 within 3U(lays or well completion per the following:
' 0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Slalic water level below lop of casing:
11'irater lere/Is above casing,use^•t•^ lr J4 0;u; Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: '(in,) 24b.For Ia.iection"Wells:Copy to I)WR,Underground hijection Control(IUC)
RotaryProgram,1636 MSC,Raleigh,NC 7699-1636
12.Well construction method: 24c.For Water Supply and Open'-Lao OperiLLlIorl Geothermal Return Wells:Copy to the
(i.c,migcr,rotary,cable,direct pushy etc.) i i , county environmental health department of the county w)ere mslalle
I
FOR WATER SUPPLY WCLLS ONLY:. j; d: G 24d.For Water Wells roducin lover 10U 000 GPD: Co to DWR,CCPCUA
�,j.,,r;,,.• PY
13a.Yield m BIOW Permit Program,I61 MSC,Rnleigh,INC 27699-IGl l
(gp ) S Method of test:
13b.Disinfection type: HTH Ambunl: 1 lb.
Forin G W-1 `'North Carolina Department of Environmental Quality-Division of Wnter Resources Revised 6-6-2018