GW1-2023-01219_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD (GW I) For Internal Use Only: �
1.Well Contractor Information:,
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM TO DFSCRiPl'[ON
3441A /70 rr. /75 fr. �-
NC Well ContmctorCertification Number flt�l� ft. 1 g ft. ! 5^
15.OUTER CASING for multi-cased we
OR LINER if n lienble
NW Poole Well and Pump Company mom To DIA11 ER TiIicimss I MATERIAL
Company Namc I- ft. S-2 fr. in.' a 02 5— 1 C,Z j
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit N: 611 w U?!rnCe p L ZZ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable n•e//construction perntas ri.e.U1C,County,Stale,Variance,ale.) ft. ft. in
3.Well Use(cheep well use): ft.
Water Supply Well: 17:SCREEN.
[]Agricultural FROM TO DfAl11EIER SLOTSILE TiIICKNFSS MATERIAL
g ❑Municipal/Public ft. it. in.
❑Geolliennal(Healing/Cooling Supply) Residential Water Supply(single)
r ft, ft. in.
01ndustrial/Commercial ❑Residential Water Supply(shared)
18..GROUT
❑ n- a�c
Nort-aVatcrSupplyWcll: ❑Wells>100,000 GPD FROM TO MATERIAL Et1IPLACEIIIENT h1EMOD d AMOUNT
© ft. ft. r
❑Monitoring ❑Recove t-�
rY ft. fe.
Injection Well:
❑A uifer Recharge ft• ft.
q g ❑Groundwater Rcrncdiation
❑Aquifer Storage and Recovery19.SAND/GRAVEL PACK if a licable
. ❑SalinityBarier FROM TO MATERAL E111PLACEBIENTMETHOD
❑Aquifer Test ..
:i ,OStornwatcrDrainagc ft fr.
❑Experimental Technology ❑Subsidence Control tr. ft.
❑Geolliennal(Closed Loop) ❑Tracer 20.DRILLING LOG nttacIt additional sheets if neccssa
❑Geothermal(Heating/Cooling Return) ... ❑Other,(explain under421 Remarks) MOM TO DESCRIPTION color,tmrdness,sod/rocktype, minsire,etc.t
ft. ft.
4.Date Well(s)Completed: 1 —/S-2z Well IDif ft• ft.
Sa.Well Location: ft•
ft. ft.
Facility/Owner Name Fiteility,1DN(if opplicable) ft. ft. J M IN 16 ;
ova Ac2S PL: Z . �� �1L
lniDi'ri%:3i,t ;1 l�ri.C=vP.�s?. Uril
Y.n P ,. �. il'l;i, ,
Physical Address,Cit ;and Zip �"•I . ' (t. ft.
�„��k�1 � 21.REMARIGS
County Parcel identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutt:s/seconds or decimal degrees:
(ifwell field,one Iat/loug is sufficient) i
22.Certiticati
�35- S3�(p5'3 N -78'314Z133 w
G.Is(nre)the tvcll(s): ❑I'crmnnent or ❑Temporary Signature ofCcrtified Well Contractor Date
:C1.;';",.: 11y signing thls form whereby certify that ihem,ell(s)was(were)constrercied in accordance with
7.Is this a repair to an existing well: ❑Ygs or �MNo /SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consin,ctian Standards and dial a cope
If ills•is a repair,fill out knoirn well constrrction htfornration and explain the nature of the of this record has been provided io ilia well oirnm:
repair larder#21 reinarks section or on the back of this forrir.
23.Site diagram or additional well details:
8.For Gcoprobe/DPT or Closed-Loop GeottlCCmal,WCllShwving die same You may use the back of this page to provide additional well constriction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary,
drilled:+ ,
} 24.SUBMITTAL INSTRUCTIONS
9.7'olal well depth below land surface: —(ft
Fornnr/rip/e fuel/s/istall depdrs lfd�e�ent(example-art 200.'and2@100') Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water level below top of casing:' ;Z G use (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Jfnarcr lavel is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 —'(in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
.'Rota
.Well construction method: ry
(i.i. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the
c,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed py
ItOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
I3a.Yield rn �G BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
(gP ) Method of test:
13b.Disinfection type: HTH Amount: 1 lb. j
FOun GW-1 ;No Carolina Department o{Environmental Quality Division of Water Resources
t � Q Y- Revised 6-6-20I C
i;t'1'�I,.r