GW1-2023-01243_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW I)
• I'or Internal Use O111y:
I.Well Contractor Information:
Landon Phillips
14,WATER ZONES
34
41 A Coulr A Nmnc ft.FROM TO DFSCRIPTION
0 rt' .S f NY)
NC Well Contractor Certification Number ft. O ft. 8j
PA
5.NW Poole Well and Pump Company FR OUTER CAoSING for ni DIADIFTERcIIs OTIII KNESSfniiliMATERIAL
Company Name ft. S fr. in. 6 1 Mc-ad
r
/ CG coritcrml-loo i
2.Well Construction I'crmit H: U�w'Ogt�l�^�22 10.INNERASING OR TUBIN nl at oser
To DIAnIE'rElt .l
List all applicable trell con.Tnvellon pertilrs rt•e.UIC,Cottay,Stare,P r•Itoal arlance•etc.) rt. ff. i Tlncxness MATERIALMATERIALatnL
n.
3.Well Use(check well use): ft. fc. in.
Water Supply Well: 17.SCREEN
❑Agricultural PROM TO DIAMETEtt SLOT SIZE TIIICIOYFSS MATERIAL
❑Municipal/Public
❑Geolherinai(1-leating/CoolingSupply) VZesidential Water Supply(single)
❑Ind ustrial/Commercial ft• ft. in.
❑lkesidemtial Water Supply(shared)
❑Irri ation 18.CROUT
Non-Water Supply Well:•
❑Wells>100,000GPD FliOai TO ItATEMAL EIIIPLA 1EN7'a1ET110D&Amouper
rt. rt.
❑Monitoring ❑Recovery
Injection Well: ft• ft.
❑Aquilcr Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recove 19.SAND/GRAVEL PACK if n licable
ry ❑Salinity Barrier FROM To NATEIUAL EMPLACDIENTMET110D
❑Aquil'er'I'cst ❑StonnwaterDrainage E
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑'Tracer 20.DRILLING LOG arlaclI additional sheds irnecessn
❑Geothermal(Ideating/Cooling Return) ❑other(explain under 921 Remarks) ]FROM To DEscuirTi color,hardnessp sotOrock type,rrain size etc.
4.I):llc Well(s)Conllllcled: S'z 2 Well IDN
5a.WellOL/ocation:
Facilily/Owner Namc Pacilily Ill#(hf applicable) s._ Z S
f fOn• KC' ��-�(.t '�rnS'1" a. rr.
PI!ysicnl Addtcss,Chk,and Zip N llt Jj.l� ft. {t• p s
1N ilf Ke 21.REMARKS 11
County Parcel Identification No.(PIN), lfliviPi;ae:!�1 ofi•:.'%st' (. ji
5b;Latitude and Imngitude in degrees/mintiles/seconds or decimal degrees: I
((i'ii1r%ve!1 ficI}d,,,one lat/long is sutlicicul)
22.Ccrlificat
N '
7�J�IZ� W
6:Is(are)the well(s): ®Permanent or OTetuporaty Signature orCeni{icd Well Contractor �- polo r Z
Uy signing rhirform,l hereby cal-10•that fire 11-01/ J was(were)constructed in accordance with
7.Is this a repair to:fit existing well: ❑Yes' ,or "UNo iJA NCAC 02C.0100 or/SA NCAC 02C.0200)Pell C0n.Tfr7rcriotr Sfandalfir and that a copy
lfllds Is a reruir,fill alit knoa•ri well construction h foronailnt'and explain die nature ofthe ofthis t•ecatrihar been provided io the ueli owner.
repair under 1121 realarkt.Tectloin or an Ilia hack ofihis forinn.
23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geotherinal Wells having Ole 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 of wells (add'See Ovef in Remarks Box).You may also attach additional pages if necessary.
drilled: i
S 24,SUBMITTAL INSTRUCTIONS
a
9.Total well depth belo,land surface: (ft.)
/"a"nrnlriple%•ll,list aNdcprhs jdbgJ rear(example-3r@200'ond2rr 100') Subunit this GW-1 within 30 days ofwell completion per file following:
10.Static water Ievcl below lop 0f casing: 0. (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
p'n•aier level is above castiig,love'I.-- Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: fill) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
12.Well construction method:
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.nugcr,rolary,cable,direct pusl4 etc.) 24e.For Water Supply: nd Omen-Loop Geothermal Return Wells:Copy to the
county environmental heatth department of the county where installed
rOIi FVA'I'LR SUPPLY tiV1;LLs ONLY:
J� 24d.For Water Wells producing over 100 000 GI'll: Co to DWR,CCPCUA
13a.Yield(glint) _ t J Dlethotl of test: BIOW Permit Program, IGI i MSC,Raleigh,NC 27699-IGI I Copy
13b.Disinfection type: HTH 1 lb.
Amount:
Form G\W-I North Carolina Deparlinent orEnvironmenlal Quality-Division of Water Resources
Revised 6-6-20I8