GW1--05522_Well Construction - GW1_20230825

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
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1.Well Contractor Information:
Landon Phillips
14.WATER ZONES I I �j
Well Contractor Name FROM TO DESCRIPTION `I
3441A d 7_5 ft. t>?ko ft. Z 5 l b/ar'I _
NC Well Contractor Certification Number 3 1s4t `3C' f t• 2 9I,,, ,�Z
15.OUTER CASING(for multi-cased wells)OR LINER(if ap iicabic)
NW Poole Well and Pump Company FROM TO - DIAMETER • THICKNESS MATERIAL _
Company Name +( ft. Q O ft. I in. . f iej/ r qG,l(/,,,,e.. /
//� � 16.INNER CASING OR TUBING(geothermal closed-loop) • • C
2.Well Construction Permit#: (l w ^
G t- Q7,450- 2_3 FROM TO DIAMETER THICKNESS MATERIAL __
List all applicable well conslnrction permits(i.e.UIC,County,Slam,Variance,etc.) ft. ft. in.
3.Well Use(check well use): • ft. ft. ! in.
Water Supply Well: 17:SCREEN •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. i
❑Geothermal(Heating/Cooling Supply) /f[t esidential Water Supply(single) ft ft. in. -"-1
0 Industrial/Commercial
❑'`Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO I TERiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. I �f
❑Monitoring ❑Recove D �lc
pea �2
ry ft. ft.
Injection Well:
ft. ft. • ---^-
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. ft. --
❑Geothennal(Closed Loop) . ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size,etc.)
0 ft. 2 ft. P SG.iL
4.Date Well(s)Completed: 3"Z 2-23 Well ID# --.2y ft. ,Zic- ft. _-
5a.Well Location: ' t-f ft. S ft. t-4/7 t(k_ -I
t s-c Ad 4m.5 14 L ft. ft. r _ _
Facility/OwnerNNaame / Facility IDii(if applicable) ft. ft.
r�C�LI�t MU-
Facility/Owner
Ovzs /,r-P(e4,sRrl�' Chdtc. i 12S'w/ffo , P/�•14) ft. ft.
5 AUG 2 5'2023 -t
Physical Address.City,and Zip A/c a7592 ft. ft. . l
k 21.REMARKS lnfofi�",2.dCft tk.^::alliWf f,.-.--...-:.:......"___I
County Parcel Identification No.(PIN) Used hardened steel drive shot �QJ!O '
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _-,
. (if well field,one lat/long is sufficient) Q� 22.Certificati 1
�5.' S1�LF N 7?). (1V29 l W
3- Z2- .3
6.Is(are)lltewell(s): ❑Permanent or ❑Temporary
Signature of Certified Well Contractor �- Date
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By signing this form,I hereby ceri fy that the Well(s)was(here)constructed is accordance with
7.Is this a repair to an existing well: ❑Yes or It No /SA NCAC 02C.0100 or 1SA NCAC 02C.0200 IVeIl Construction Standards and that a co.rtr
If this is a repair,fill out known well consin,ction information and explain the nature of the of this record has been provided to the well a burr.
repair under 1121 remarks section or on the back of this 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 ink
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessah
drilled:I
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SOS ft
Fa nu ltiple wells list all depths efrl ereul(erau,p/e-3 a?00'and 2�100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" �� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC')
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary_ t
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to th.:
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmentlof the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) c! Method of test:
BLOW Permit Program,161 I MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTN Amount: 1 lb.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ! • Revised 6-6-201 i