GW1-2023-01212_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD (GW_,I„), For Internal Use Only:
I.Well Contractor Information:
Landon Phillips 14.WATER ZONES J
Well Contractor Name FROM TO DESCRIPTION
3441 A ' ?o rt. S It.
rt. d...a• l S NC Well Contractor Certification Number
15,OUTER CASING for multi-cased wells OR LINER if n licnblc
NW Poole Well and Pump Company IROM TO DIAMETER TIIICI{NESS MATERIAL
n.
Company Name �vI r p
It
INNER
tt++ IG.IER CASING OR TUTTING eothermal elo3cd-lao i
2.Well Construction Permit M:-&G/'—&')o 9 2O2 ITROM TO DIAMETER I THICKNESS MATERIAL
List all applicable sreif cons(ruciton permits(i.e.UiC,County,State,Variance,etc.) ft. R. in
3.Well Use(elleclt well use): It. [t. in.
FOAgricultural
Well: 17:SCREEN.
FROM TO DIAMETER SLOT SIZE TIIICKNF.SS MATERIAL
❑Municipal/Public ft Healing/Cooling Supply) sidential Water Supply(single) r�af/o1<ft. ft.mmercial ❑Residential Water Supply(shared) ill.GROUT
❑Wells>100,000GPD FROM TO MATERIAL r rhIPLACEaIENTAlKMOD&MOUNT
Non-Water Supply Well: (1i ft. 2 CJ ft. � IDA t he r
❑Monitoring ❑Recovery
Injection Well:
tr.❑A uifer Recharge ❑Groundwater Rcmediation ft.
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACK ira licablel
❑Salinity Barrier FROM TO 51ATEItIAL . EMPLACEMENT1nETHOD
❑Aqui far Test ❑StormwatcrDrainage Cj ir• 'fJr rr. #3
❑L"xperimental Technology ❑Subsidence Control tt. tt 'Pau It-
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING.LOC attacli additional sheets irneccssa
❑Geothermal(1-leating/Cooling Return) ❑Other(explain under 421 Remarks) I FROlnt To 1 DESCRIPTION color,linrilness,soil/rock t a rAn sire,eta
U rt. dl rt. To `Sa
4.Date Well(s)Completed: /O-Z 7^Z 2 Well IDti rr• L�U rL A
5a.Well Location: ft. !/eft. Cman F e
/ ft. ft. m,+i
trA �QMBS
Facility/Owner Name (( A[ Facility ID8(ifapplicable) ft. ft. AN �
_ / f/nD iG nJ IC N (./ fr. It.
�t'O
A2—�C•�[a� /�L Int•r-r::iMiaotr�t ?••� tit
Physical Addmss,Cily,and Zip ft.
21.REMARKS
Cowily Parcel Identification No.(PiN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifsvcll field,one IaViong is sufficient) 1,
22.Certificati
W
6.Is(are)the wcll(s): Permanent or ❑Temporary Signature o£Ccrtifted Well Contractor Date
fly signing this form.]hereby certify that them efi(s)was(were)construcred in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 01C.0100 or ISM NCAC 02C.d100 lfrell Coirsirriciiou Standanfr and ihat a copr
!f this•is a repair,fill out known well coiisiniclioir hifornigtioir and explain ire irature of the of this record has been provided to the welt owner.
repair raider 1111 rentarkr sectlon or air the back of this form.
� 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 Ovee in Remarks Box).You may also attach additional pages ifnecessary.
drilled:+ ' '� t:'
24.SUBMITTAL INSTRUCTIONS
9.'Total well depth below land surface: I1 YV 1/
Gt (rt.)
FormidUple wells Astall depths rfdVaretit(example-3@100'and2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z o (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
if carer level is rebore casing,use'i" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 '(in,) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
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 producine over 100 000 GPD:Copy to DWR,CCPCUA.
13a.Yield(gpin) a� Method of test: BLOW Permit Program, 1611 MS
C,Raleigh,NC 27699-I6I I
13b.Disinfection type: HTH Amount:
Ironn GW-1 North Carolina Department of Envimnmental Quality-Division of Water Resources Revised 6.6-201 C