GW1-2023-01220_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: V
1.Well Contractor Information:
Landon Phillips 19:,WATER:'ZONES �_
Well Contractor Name FROM TO DESCRD'rION
3441 A 66 ft. 04S ft.
®//,
NC Well Contractor Certification Number 3 76 ft- ft- 6- '1
;yI5:.:0UTER;CASING'foriinniti cased wells OR LINER'.ifa "licalile
NW Poole Well and Pump Company FROM TO DIAMETER THICKNEss MATERIAL
Company Name (� ft 3 ft. m f5(dh f 5e,1U[M t'
I^f s N C�-o 9 ZZ I Z `G INNER CASING OR-'TUBING eothetmai closed•loo
2.Well Construction Permit#:"y FROM TO 1 DIA1 ]MR I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Parlance,etc.) ft. ft. Ia
3.Well Use(check well use): ft. ft.
Water Supply Well: 47.:SCREEN
❑Agricultural ❑Municipal/Public
FROM TO DrAMEI'ER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1 JResidential Water Supply(single) ft. &
,AL,dustrial/Commercial ❑Residential Water Supply(shared) gEi.GROUT "
❑Irri ation ❑Wells>100 000 GPD FROM TO' TERIAI, E1IIPLACEMENT ALUMOD&AMOUNT
Nan-Water Supply Well: " 20 ft " m v
❑Monitoring ❑Recovery ft. ft. 1
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
A93AND/GRAVE-PACK`ifa "liciible,'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACFMEn METHOD
❑Aquifer Test :j ,j e i �; 13 tormwater Drainage ft. ft.
❑Experimental Technology, ❑Subsidence Control & ft.
❑Geothermal(Closed Loop) ❑Tracer RO:DRILliING'LOG eitacfi BddiHonut sheets'ifnecessa ,
FROM TO DESCRI ITON(color,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) . -.❑Other(explain under#21 Remarks fL ft.
' d o)P Sd z
4.Date Well(s)Completed: `ZZ Well ID/0 ft ft. I
C
5a.Well Location: (�GS ft.
ft. ft
Facility/Owner Name Facility IDff(if applicable)
ft ft.
Physical Address,City,audZip ft ft 1fi+s�re{iFi.t l �tC` �y`?F7Gn:1
W GL,/fit 21REMARKS
County Parcel Identification No.(PIN) Used hardened steel drive shoe.
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i£well field,one!at/long is sufficient)1 I � l l!; •'. f C 1 1 22,CertiScati
�`�.Ii 'd, w
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
1 By signing this form,I hereby certtjy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes. or IlNo 15A NCAC 01C.0100 or 15A NCAC 01C.0200 iPell Construction Standards and that a copy
If this is a repair,fill out known well construction infonnation and explain the mature of die of this record has beenprovided to the well owner:
repair render#21 remarks section or on the back of fiefs 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdeerent'(exarnple-'3@200'aitd 2@1001) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:.
Ifiater level is above casing,use"+" Information Processing Unit 1677 MSC,Raleigh,NC 27699-1617
il
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary 12.Well construction method: 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUE;
13a.Yield(gpm) �O Method of test: BLOW
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb,
Form GW-1 Noith Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018
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