GW1-2023-01235_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW 1
• � For Internal Use Only:
I.Well Contractor Information:
Landon Phillips
14.IVATER ZONES
R+ell Conlrndor Nmno FROhI TO DFSCRIPTION
3441A------------
NC Well Contractor Certification Number o2(QO ft 'l� ft. �—
I5.OUTER CASING for multi-cusc Irdls OR L[NER if n NW Poole Well and Pump Company FROal itirnblc
7'D DIAaI�ETER TIIICI(NE•SS nI/ATL•RIAL
Company Nnnic .�(. ft. ro<" rt. (�' In, t D d G"74 ✓
�_O 7� St 16.INNER CASING Oil TUBING cotitcrntal closed-loop)2.Well Construction Permit il:_:�? —2 pZ Z FRont To I DIAME'I'EII THICKNESS MATERIAL
Ids/all applicable hell coiara-uaion poritars rr.a.UIC,Caiolty,State,parlance,era) ft ft.
3.Well Use(clleclt nvell use): ft ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural FROM TO DIAMETEtt SLOTSIZE TIfICIOYESS MATERIAL
❑lAunicipal/Public ft R in
❑Geothermal(ldeating/Cooling Supply) DiC.-idential Water Supply(single)
❑industrial/Commercial
❑Itcsidential Water Supply(shared)
❑lrri anion S.GROUT
❑Wells>Non-Water Supply Well: IOO,000GPD FROM rt. TO MATERIAL EAIPLACE51ENTNIETIIOD&AMOUNT
ft.
❑Monitoring ❑Recove f D S a� .l('9 e>
Injection Well:
ft. fr.
❑Aquilcr Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GIIAVEL PACK If n Iicable
FROM TO MATERIAL EMPLACEDIENTMETHOD
❑Aquitcr'I'csl ❑SIOrlilwater Drainage ft. ft.
❑L•xperimenlal•I'cchnology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addlfionnl sheets if necessary)
❑Geothermal(hleating/Cooling Relum) ❑Olhcr(explain under#21 Remarks). Moat TO DESCRtrTION color hardnes sai0rocn lync.gmill sire ctc.
ft. a ft. —
4.Dale Well(s)Co � ,
nplcled: 5 U- Well ID/1 a ft. ft.
5n.Well Location: ft. 3 e, ft.
C r AK,
f_?/1 r
rncility/Owner Namc racilily IDH(ifapplicable) ft.
//2 N /C P i 7"h5 r� / /G!/1 IC/7�i lam / ft. ft. M.
!`�""7
Physical Address.City,mid Zip ft• ft. J A N J
e—)of Ile 21.REMARKS
County
Parcel Identification No.(PIN) Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IoUlong is sufficient) I
N -711�I�I O ChU1 W
6-Ware)the tvell(s): I&Perulolent or ❑T6milorm), Signature ofCcrtifted Well Contractor
B)'signiiib this form,)hereby tortif that the wall(r)u•as(a•ero)constructed in accordance frith
7.Is this a repair to an existing t1'eli: ❑Yes .Or LRJNo 15A NCfIC 02C.Oloo a•15A NCAC 02C.0200 IFe11 Construction Standards and Char a cop),
!f,'thir is n repair,fill am knau•n u•cll caisn•ncriau hr/bruiatnn mid etplain die unno•e of the njrlris recorrllrcia Gecu provided to tl�e u•c!l otrncr.
repair untler 1121 reniarkr section rn•oil the hack ojthis fount.
' "' 23.Site diagram or additional ivell details:
3.For Geoprobe/DPT or Closed-Loop Gcotherntal Wells having the same You may use the back of this page to provide additional well construction info
Construction,only I GW-I is needed. Indicate TOTAL NUMBER ofwelis (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: I
24.SUBMITTAL INSTRUCTIONS
9-Tobll well depth below hand surface: 3 G -
runt nudtplc uc11,r list n11 depths lfel ercnr(crm aople-3 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
I I
10.Smile water level below top ofcasing• Z�� (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
?/hater level is whore casing,ttse"•r(",, information Processing Unit,.1617 MSC,Raleigh,NC 27699-1617 -
I I.Borehole diameter: "� (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(RUC)
12.Well Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
construction method:
(i.e.nugcr,rotary,cable,direct push,etc.) 24e.For Water Supply and Open-Loop Gcotherntal Return Wells:Copy to tine
county envirotunenlal health department Of the county where installed
FORWA'I'LR SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 Gl'D:Copy to DWR,CCPCUA
13a.Yield(gpin) 11'Iethod of test: Blow Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
rorut G11+-I North Corolinn Department ofEnvironmcnlal Quality-Division of Walcr Resources
Revised 6-6-2018