GW1-2023-00891_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon PhIIIIpS 14.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
3441A 7� rL it. �;^
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable
NW Poole Well and Pump Company FROM Tp DIAMETER THICKNESS MATERIAL
r'b Q ft. ft. (47 in.
Company Name
I h 16.INNER CASING OR TUBING eothermal closed-lot
2.Well Construction Permit#: OF FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable irell construction permits(i.e.UIC,Coraq,State,Variance,etc.) ft. ft. in.
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it 3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROIREETO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
i ❑Geothermal(Heating/Cooling Supply) ;,Mf esidential Water Supply(single)
ft. ft.
❑Industrial/Commercial Glkeside'ntial Water Supply(shared) 18.GROUT
I ❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EIIIPLACEIIIENT il1ETIOD&AIIIOUNT
Non-Water Supply Well: ^) R. ft.
❑Monitoring ❑Recovery ( ft. I. _ at�;ztkul 'Isd
Injection Well:
ft. ft.
j ❑Aquifer Recharge ❑Groundwater Remedialion
j 19.SAND/GRAVEL PACK if n licable '
i ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL• EMPLACEMENT METHOD
j ❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology '❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color hardness,soil/rock type,amin sac,etc.)
❑Geothennal(Heating/Cooling Return). ❑Other(explain under#21 Remarks) Ia,C) it. ft.
s; fi
i j 4.Date 11 ell(s)Completed:G_1-qT�"_`�Z- ft. ft.
ID# � �7�
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5a.Well Location: (�� ft. ft.? ,meµ f• ., ,! ! !r'
A i ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. JAN 2 0 2023
I f ft. ft.
I r
Physical Address,City,and Zip ft. ft. ...'r .fix
I `l 21.REIIIARI(S
II County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(ifwell field,one IaUlong is sufficient) 22.Certificat'
Wooglb N Z V.22701Li- W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCenified Well Contractor ` Date
By signing thus formn,1 hereby certify that the u•ell(s)was(were)constitcted in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200)fell Consirrctlon Standards and that a copy
If ibis is a repair,fill out lmou,nr ivell construction information and explain the nature of the ofthis record has been provided to the well turner.
I repair under 921 renrarla•section or on the back of this fora.
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 well construction info
construction,only 1 GW-1 is needed. hldicate TOTAL NUMBER of wells (add'See Over'ht Remarks Box).You may also attach additional pages if necessary.
drilled: t
F 24.SUBMITTAL INSTRUCTIONS
i 9.Total well depth below land surface: C1- ft.)For multiple}cells list all depths fdgerent(example-3 200'aild 2@100') ( Submit this GW-1 within 30 days of ivell completion per the following:
10.Static water level below top of casing: ft 24a• For All Wells: Original form to Division of Water Resources (DWR),
Ifurater level is above casing,use'•+.. ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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Rotary Program,1636 MSC,Raleigh,NC 27699-1636
j 12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over IN 000 GPD:Copy to DWR,CCPCUA
13a.Yield m Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP ) Method of test:
j13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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