GW1-2023-00913_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: r �-
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1.Well Contractor Information:
Landon Phillips 14.WATER ZONES'
( FROM TO DESCRIPTION
i Well Contractor Name ft. I ft. eA11401
i 3441 A t
7 5 rt. ft. A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LiNER if n ilicable
NW Poole Well and Pump Company FROa1 TO DI .heAllt Tu.C-N ss afATEIiI,\L
rr. fr. in. �pw
Company Name s
��3CASING OR TUBING colhcrmal closed-loop
2.Well Construction Permit#'-; FROM TO DIA\PETER THICKNESSESESS a[,\TERIAL
List all applicable yell constriecdon pernrirr(i.e.UIC,Calmly,State,Variance,e(a) ff. ft.
3.Well Use(citech well use): ft• ft. tn,
17.SCREEN
Witter Supply Well: rnoAl TO DUAIETER SLOT SIZE TIIICKNESS MATERIAL
❑Agricullurai ❑Municipal/Public ft. ft. la
❑Geolhennal(1leating/Cooling Supply) kResidential Water Supply(single) ft• ft• to
j ❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
j ❑Irrl ation ❑Wells>100,000 GPD FROM I TO D ATERb1L EAIPLACEhIENT 5 LT110D&AMOUNT
j Non-Water Supply Well: O ft. ft. �p 1
❑Moniloring ❑Recovery, ft. rL
Injection Well: ft. ft.
{ ❑Aquifer Recharge ❑Groundwater Rernediation
19.SAND/GRAVEL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO51 TO MATERIAL EMPLACEMENT ArETnorl
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y ft. ft.
❑Aquifer Test ❑Stontttvater Drainage
❑Experimental Technology ❑Subsidence Control ft• ft.
j ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG aunch additional sheets If necessary)
r•Ro51 TO DESCRIPTION color,hardness,solprock f e, rain size,etc.)
I ❑Geolhennal(Fleating/Cooling Return) ❑Other(explain under#21 Remarks) tt. fr.
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4.Dntc 1Vcll(s)Completed: _1 -2 Wcli IDl/ tt. S ft. 1C /61 y
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5u.Well Location: ft• rt. ��kh
facility/Owner Name n Facility iDP(if applicable) ft. ft.
3 JoZ� ��tACG �9'G..r-�-t' wC �G►�� '�0 C�$od rr. rt.
Physical Address,City,and Zip NZ `?�g ft. ft.
21.REMARKS r
C tA/ Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifss•cll field,one]at/long is sufficient) 22,Certifrcnt'
N �Q�.5qo15 W I _ r r-z�
6,•Is(are)the wcll(s): LAPernia tent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certlfj,that ilia irelf(s)eras(were)constructed in accordance with
7.Is this a repair to nit existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 11'ell Construction Standards and that a cap)
y'rin/s is a repair,fill out known we/1 construction information and explain ilia nature of ilia of this record has been provided to ilia well of ter. i
repair under it21 remarks section at-on rite back of this form.
23.Site diagram or additional'tvcll details:
S.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 I GW-i is heeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBNUT"TALINSTRUCTIONS
9.Total well depth below land surface: �O S (ft.) Submit this GW-1 within 30 clays of well completion per the following:
For multiple trells list all depths ifd 'erent(example-3@200'and 2@100�
q O 24a. For All Wells: Original font to Division of Water Resources (DWIZ),
10.Static water level below lop of casing: 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifirater level is above casing,use'•+"
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(fUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
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 producing over I"'00 GP
Copy to DWR,CCPCUA
BIOW Permit Program,1611 MSC,Raleigh,NC 27699-161 l
131.Yield(gpin) Method of test:
HTH 1 lb.
13b.Disinfection type: Amount-
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018