GW1-2023-01221_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Landon Phillips WATER ZONES J
Well Contractor Name FROM TO DESCRIPTION
3441 A
C!.
NC Well Contractor Certification Number 3�5 ft. a -
15.OUTER CASING forlti-cased wells OR LINER Qfnp licable
NW Poole Well and Pump Company IFRoM mu
TO DIAMETER TIIICItNESS MATERL.L
Company Name J-/ ft. /J'f ft. & in.' ?/ � v
16.INNER CASING OR TUBING eothermal ciped-loot l•
2.Well Construction Permit#: a oe_z FROM TO DIAMETER THICKNESS MATEat AL
List all applicable urell construction permits(l.e.UIC,County,State,Variance,etc.) ft• ft.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN.
]FROM TO DIAhtECER SLOTSIZE TnICKNF,SS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Colntnercial ❑Residential Water Supply(shared)
18.,GROUT
❑lrrl ation- ❑Wells>100,000 GPD FROM TO MATERIAL E51PLACENIENT AIEFHOD&AMOUNT
Non-Water Supply Well: tt. Zp ft.
❑Monitoring ❑Recovery ft. ft. '
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salini Barrier
SAND/GRAVEL PACK if n licable
ty er 19FROM I TO MATERIAL EMPLACEMENT 1HErHOD
❑Aquifer Test OStormwatcrDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,knrdnan,soil/rock type, rain site,etc.❑Geothermal(EIcatinglCooling Return) ,❑Other(explain under il21 Remarks)
ft. ft.
4.Date Well(s)Completed: 1 I ' 7 Z� Well IDIf f. ft.
Sa.Well Location:':, ft. A.
/ ft. ft. LA e>
Facilitt``y/O//wnerName FncilityIDA(ifapplirable) ft. ft. gng
4 JAN A 7 3
DLJ/l0 L t,ti; %ll: ft. ft. IV LIJL
physical Address,City,and Zip
t-,�ctic P 21.REMARKS
County ;I i. Parccl Identification No.(PIN) Used hardened steel drive Shoe.
5b.Latitude and longitude in degrees/minutes%s,ecends or decimal degrees:
(ifwell field,one IaUlong is sufficient), 'I i s 7 22.Certiticati
3S �i37C�5®[ N —1$1,' '6 712(0 W
//-iS=2z
Signature ofCertiftcd Well Contractor Date
G.Is(ari:)the\vcll(s)c ❑Pcrmnnent or ❑Temporary -
i By signing this fornr,l hereby certify that the,well(s)mas(ivere)constructed in accordance trirh
7.Is this a repair to an existing well: ❑Yes' or"'InNo 13A NCAC 02C.0100 or/SA NCAC 02C.0200 7frel/Construction Standards and that a copy1f ilds is a repair,fill out known trell construction hr/pnnati"on and explain the nature of the Of this record has been provided to the well ai nen
repair under#21 remarks section or on the back ojOtls form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop GeothprmalWells having die 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 maymiso attach additional a es if necessa
drilled:+ P g ry•
24.SUBMITTAL INSTRUCTIONS
9.'I'olal well depth below land surface: t f
/a nnrltple a el/s/tut a!%deprhs ifdperen (exarnp/e=.3Q1001 brad 2Q100') ( ) 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,
0.Static water level below top'of casing: ! ' I'✓`CJ fL g ( )
If water level is above 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(fUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: ` 'J" 7"
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpin) Method of test: BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disilifeclion type: HTH 1 Ib.
Amount:
Fonn GW-1 Nomh�Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2013