GW1-2023-01175_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Lttemal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
well Contractor Name FRODi TO DESIP CRTION
3441 A �o ft• ltS rt. ao G
NC Well Contractor Certification Number
70 ft. 1 ]s fl. )o 6 p 1-i.
15.OUTER CASING for multi-cased wells OR LINER if a tlicablc
NW Poole Well and Pump Company FROAI TO DIAMETEIC TnICKN(E�SS MATERIAL
d ft. 1 fr. G in. lr0 6 AL t/
Company Name tX �
f ,_ 6 6�$"7�_aUa 16.INNER CASING OR TUBING anther ill closed-loo
2.Well Construction Permit It: w FROat TO IDIAAIETER THICKNESS MATERIAL
Un till applicable n•e11 coltslrnclion per,11lr(i.e.U1C County,State,Yarlaace,etc.) ft. ft. in.
3.well Use(checlt well use): ft. ft.
Water Supply Well: 17.SCREEN
FROA1 TO DWAIETER SLOT SIZE THICKNESS AIATERLIL
❑Agricultural ❑Municipal/Public Q rr. go ft. `F in. 6 ,aS0 PV[ ,
❑Geothermal(hreating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18,GROU'P
❑Irru alion ❑Wells>100.000GPD FROM TO AIATERUL E5IPLACEIIIENTa1ETHOD&AMOUNT
Nou-Water Supply Well: O ft. ft. +�
❑Monitoring ❑Recove a� B1 rt�ail t��
iY ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft,
19.SAND/GRAVEL PACK(ifatirdicable
❑Aquifer Storage and Recovery []Salinity Barrier FR05I I TO I MATERIAL I EaIPLACENlENT51ETllOD
❑Aquifer Test ❑StonmvaterDrainage O ft. $0 ft. 3 G ehtf�L /?E►1j
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,saillrock type,grain size etc.)
0 ft. a ft. T 5 I L
G
4.Date N1101(s)Completed: ✓7rdd Well IN a ft. R ft. 5,JWb i L Lk
5a.Well Location: ft. ft. &RA:r I
rGRN Roob a-rL ft. (,-, K CRA^))T(C
Native Nae Facility 109(ifapplieable) ft. ft. SUr a t` (�'I T
333D FEE LF S RGA'6 i AL, . Nc a761L fr. ft.
Physical Address,City,and Zip ft. ft.
f.to 21,REMARKS
Co�unn/y+e Parcel Identification No.(PIN) JAN G ' 1l
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees: I1
(if'well fielld/•onef fatllong is sufficient) c�, 22.Certifncat'
5.D71D�5 N 4.7
6.Is(are)the well(s): ®Perninnent or OTcmporary Signature ofCcri fled Well Contractor Date
By signing this form,l hereby certo,that the uvell(s)tras(were)constructed in accordance u1th
7.Is(his a repair to an existing well: Oyes.. or InNo 15ANCAC 01C.0100 or 15ANCAC 02C.0100 Well Construction Standards and that a copy
lJ?his is a repair;full out knonru well construction hnforaation and explaht the nature ofthe ojthis record has been provided to the irell turner.
repair under#11 remarks section ar oil the hack ojthis fora.
• �•l, 23.Site diagram or addilional'well details:
S.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 1 GW-1 is heeded. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)Fa•multiple trells list all depths ifd tt Brent(example-3 100'and 2@100) Submit this GW-1 within 30 days of well completion per(lie following:
10.Static water level below top ofcasing: IU (It 24a, For All Wells: Original form to Division of Water Resources (DWR),
lj'traler level is above cashtg,use"+^; / ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: l0 (la,) 24b.For Injection Wells: Copy to DVdR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.auger construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.organ,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR aa'ATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD: Copy to DWR,CCPCUA
13a.Ytcld rn 3� Blow Permit Program,1611 MSC,Ralell NC 27699-161 l
(gP ) Method
13b.Disinfection type: HTH Amount: 1 lb.
Fond GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018