GW1-2023-01173_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use ODIy:
1.Well Contractor Information:
Landon Phillips la,1YATERZONES
Well Contractor Name FROM I TO DESCRIPTION
3441 A ft• ft.
ft. R.
NC Well Contractor Certification Nwnhcr
15.OUTER CASING for multi-cased wills OR LINER if n s licnhlc
NW Poole Well and Pump Company EROM1 ,� bat TEa TIHCICNES$ MIATERIAL
Company Namc fI, m 1 In.
16.INNER CASING Olt TUBING codlnernhnl closed-loon)
2.Well Construction Permit t1: C'w -��7�� °� rROAI I To I DIAMIE•rER I TtI1CICNrSS I MIATERIAL
1.lst all applicable well ewasn•uction peratlrs('11.a.UIC,Catinly,State.Partance,eta)
3.Well Use(chceit,vell use): rr. rt. is
Winter Supply Well: 17.SCREEN
❑Agricuhural ❑Municipal/Public
FROM TO DWIETER SLOT SIZE THICKNESS MATERIAL
� rr. � s'rL I°' O ,asV �
❑Geothermal(1-leating/CoolingSupply) ❑Residential Water Supply(single) rr. ft. In.
❑Industrial/Commercial -' ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation []Wells>100,000 GPD FROMt TO MIATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Rcchargo ❑Groundwater Remedialion ft. ft.
•
❑Aquifer Storage and Recovery ❑ 19.SAND/GRAVEL PACK if n licablcSalinity Barrier FROMTU MIATERAL EDIPLACEMIENTh1ETIlOD
❑Aquilor'I'csE ❑Stonmvater Drainage ft: ft.
ClLeperitnental'l'eclinology OSubsidenceControl n. I ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG ntfach nddltionnl sheets Irnecessn
❑Geothen-nal(1-leating/Cooling Return) ❑other(explain under#21 Remarks) 1711051 TO DESCRUIT1 N color,hardness stilyruck tylic, rain size etc.
4.Date Well(s)Completed: S+o -djWeI11Dhl
�
a"a.Well Location: Ct. ft.
Pacilily/Owner Nanic tracility 1DH(ifopplicable) ft. ft.
7 _ 1 C E r E,S
Q_I o Z (),A, Q W , f . rt.
S
Physical Address.City,and Zip d DSO 7 ft. ft.
C / �A V- 21.RE51ARICS IRS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/mhnttesh cconds or decimal degrees:
(ifwcll field,one InUlang is sufficient)
22.Ccrtificat'
125�� IN 7V:I W
6:Is(arc)the well(s): ®Permmncut or OTeniporary Signature ofCcnifted Wall Contractor Doc
Up signhhg this form,I herebt,centl(that to we//(r)was(were)constructed in accordance with
7.Is this a repair loan existing well: ❑Yes or InNu 15A NGIC 01C.0100 or ISA NCAC 01C.0100 Well Cotistnicrion Srandards and that a Copp
11•t/tir is a repair,fill out knmrir o•eR consa•ttclion it farernilon and explain fire nature of the afthis record has been provided ra the well owner.
repair antler 1121 renarks.section or an the back of this form.
23.Site diagram or additional well details:
8.For Gcoprobe/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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (ndd'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: 6/ (R•) Submit this GW-1 within 30 days Orwell completion per the following:
For nndtiple u•e//.s list all depths tfdiJfcrctrt(exantple-3@100'and 1 a 100')
10.Sinlic water level below lop of casing:- A— (ft.) 24n. Fur All Wells: Original form to Division of Water Resources (DWR),
//'water level is above cashrg,use•'•n-" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 -
11.Borehole diameter: C (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(JUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.11ne11 construction cable,
method: 24c.For Water Supply and Open-Loa Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pasty etc.) county envirolunental health department o the county where installed
FOR WATER SUPPLY WELLS ONLY:. 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpun) f J• Method of test BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
I
Dann OW-1 North Carolina Department of Environmental Quality-Division of Wnler Resources Revised 6-6-2018