GW1-2023-01233_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
I.Well Contractor Information:
. Landon Phillips -
14,1VATER ZONES
Well Conlrnclor Name FROM TO I DESCRIPTION
i
3441 A ft. 1 rt.
ft. IR.
NC Well Contractor Certification Number
15,OUTER CASING for mull(-cased wells OR LINER If n ilicablc
NW Poole Well and Pump Company FROM 1'0 DIAMETER FT it MATERIAL
Company Name
/ 16.INNER CASING Oil 3'UBING eolher,iml closed-too i
2.Well Construction Permit 1y: C ^ (��)I� — eon FROaI TO DIAMETER TIIICKMES— MATERIAL
l.lrt a/lapplfa+hle u•e/I connnrclion perrnlLs(i.c.UIC,Canary,State,Iforiance,etc.) ft, ft. in.
3.Well Use(clleclt well use): fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE TIIICIW ESS MATERIAL
❑Agricultural ❑Mwuicipal/Public fr. fr. in.
❑Geothermal(1•Icating/Cooling Supply) idential Water Supply(single)
in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irri ation ❑Weils>inn nnOGPD FROM TO DIA9'EIiIAL EMPLACENENTMETIIOD&AMOUNT
Non-NI,
n terSupply'We": ft. L.6 , ' of
❑Monitoring ❑Recovery ft. ft
hljcclion Well:
❑A Uil'crRechar c ft• ft•
q g ❑GroundWaler Remediation
19.SAND/GRAVEL PACK Ira liable,
( A❑AquiferSloragemtdRecovery ❑Salinity Barrier FROM TO E51PLACC•111ENTMETIIOD
❑Aquilcr'I'cst ❑Stormwater Drainage ft. ft.
❑Gxperinienial'Technology ❑Subsidence Control ft. A.
❑Geothermal(Closed Loop) ❑'Tracer 2o.DRILLING LOG attach odditionnl sheets If neccssa
❑Geothermal(1-I eating/Cool i jig Relum) ❑Other(explain under 921 Remarks) FRoai TU ur2mr•riory color,Itardaes,,ollfrock type,groin,-u cfc,
Cy ft, a ft. 10 coo'1
4.Dalc Wcll(s)Ctnnpleled: O-10--m Wcll iDN a ft. ' ?
5a.Well Locatlon: ft• t�f fl. J- ll
7 n! T
ft. ft.
Iracilily! caner Namc Paciiity,IDN(if applicable) ft. ft.
��I"- /�• I 1 �/1
—� 4m-i2� L l /� r�/c /i l,44/C 7 1 r fl. rt.
Physical Addrass,City,and Zip ft. ft. , O
21.REMARRS
Count}' Parcel Identification No.(PIN)
5b.Latitude Iuul longitude in degrees/minutes/seconds or decimal degrees:
(if'wwcll field,one Iat/long is sufficient) 'oe `y (yQ 22.CCI llfiC7l t'
�1 ��N —Istt -\U W
6:Is(are)the well(s): ®Permanent or ❑Temporary Signature aCCertified Well Contractor ` Date
By Signing Iliis fora-,I hereby certify that/lie well(s)was(here)constructed in accordance iritlr
7.Is this a repair loan existing well: ❑Yes: or EiNo i-SA NCAC 02C.0i00 or ISA NCAC 02C.0300 IPell Consrnrction Srmnlartls and drat a copy
/J'Ihdr is a repair,fill out known irell constructiot h formarlon nod explain ilia nature ofihe ofthis record liar been provided to Ore ire//owner.
repair under 1121 reinarkr section or oil ilia back ofthisfornl.
23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Ivell 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: - I "
6 1 � 24.SUBMITTAL INSTRUCTIONS
t
9-Total well dcptlr below land surface:
Far,nitiple n•el/,s list (
all depths ljdAerent(exampla-3@200•and 2@1u0') —(ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Slatic water level below lop of casing:_ (7 . (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1111-ater•level is above casing,use••-i••• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
r_ -
11.Borehole dinnieter: `� (in.) 24b..Tor Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well ul;cr conry,cable, method: 24c.For Water Supply and Open-Loop Geothermal Return 1Vells•Copy to the
(i.c,migcr,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR\VA'I'LR SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD: Copy to DWR,CCPCUA
13a.)'field mr BIOW I'ennit Program,I 1 MSC,Ra eigh,NC 27699-161 l
(6[ ) Method of test:
13b.Disinfection type: HTH AmounAmount: 1 lb.
Form GW.I Non Carolina Deparnnent of Environmental Quality-Division oCWater Resources Revised 6-6-2019
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