GW1-2023-01050_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES I !
Well Contractor Name FROIII TO DESCRIPTION I
3441 A [Cf S `t• ISOa
rc. rt. I
NC Well Contractor Certification Number7 5 15.OUTER CASING for multi-cased wells OR LINER if a ilicablc
NW Poole Well and PUMP Company FR011r TO DIA51ETEILI TIIIC N S TtATER1AL
Company Name ft. . >w�w
/ 16I ER C NG cothermal closed-loon)
2.Well Construction Permit H: a3 DIAMETERI I TnirtcNE55 MATERIAL
List all applicable ire/l construction peroats(i.e.U1C,Coma};State,Variance,eta) ft.
3.Well Use(cllecl(well use): B. ft.
Water Supply Well: 17.SCREEN
FROaI TO DW IETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. 1
❑Geothermal(Ileating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial -❑`Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROhf I TO a ATERWL EMPLACEMENT A � IIOD&AMOUNT
Nou-Writer Supply Well: O ft. ft. �iP r
❑Monitoring ❑Recovery
Injection Well: 1
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑ 19.SAND/GRAVELPACK ifalicablcSRlinily Barrier FROM TO I MATERIAL EIIIPLACENIENTNIETHOD
ClAquifer Test ❑Stonmvater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geother ial(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(I-fea[iug/Cooling Return) MOM TO DESCRIPTION color,hardness,soll/r•ock type, rain size etc.)
^�� ❑Other(explain under#21 Remarks) ft. tr, •5 15
4.Date Well(s)Completed: Well IDII tt. S ft. It/
5a.Well Location: ft. O ft. rkh
�'( ft.
facility/OwuerName Fac�illiityl�rDB(if applicable) ft. ft.
1
Physical
Address,City and Zip ft.
ell? JA N 6
zL REMARKS
C Parcel Identification No.(PIN) In�iiYE3ii_S :�i:-::;.:i• ,;,,�
5b.Latitude and longitudein degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient)
zz.cerlifieal•
Lf.o7 -I _N �� 5q,o15 W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
Bysignhng this form,I hereby cert fy that the:ivell(s)was(here)constructed Dr accordance with
7.Is(his a repair to an existing well: ❑Y,es: or MNO 15A NCAC 02C.0100 or 15A NCAC 01C.0100 II elf Construction Standards and that a copy
ffthis is a repair,fill our known well construction b jorivalion and ezplahs the nature ofthe ofthts record has beenprovided to ilia ire/1 owner.
repair under.1111 remarks section a•on the back of this foam. I:
1, 1' I� 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 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: 24,SUBrv=AL INSTRUCTIONSi'
• � Cil i ilb,
9.Total well depth below land surface: I . S (ft.) I
For multiple wells list all depths ld(Jferent(example-9 a 100'and 1p100) Submit this GW-1 within 30 days orwell completion per the following:
i ofcash 24a. For All Wells: Original form to Division of Water Resources (DWR),
70.Static water level below to
I g: O (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1firater level is above casing,use"+" 1• ,1,
11.Borehole diameter: (In-) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and O en-Lo I op Geothermal Return Wells:Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY\i'Tj LLS ONLY: 3? 24d•For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Ib I:II'f BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.1'ield(gpm) I1•letin d of test• III
13b.Disinfectitin'type: HTH Amount: 1 lb. I
Furnii GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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