GW1-2023-00914_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: D q_ + _
1.Well Contractor Information: R E�El LS
Landon Phillips 14.WATERZONES
I FROM TO DESCRIPTION
I Well Contractor Name V
3441 A o rt. q %
+dn 13 ^r n
rt. fL DW'C MOG
NC Well Contractor Certification Number 15.OUTER CASING for mrilli-cased wells OR LINER if a licablc
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. w k J�
Company Name � r
16.INNER CA ING OR TUBING Neotheriataf closed-loo
2.Well Construction Permit#: W5 NCIf-o3cl OQD. FROM TO DIAMETER I TICKNESS I MATERIAL
LLri all applicable yell construction perurits(i.e.UIC,County,Slate,lrarlance,etc.) ft. ft. in
J3.Well Use(clieck well use): ft. ft. in.
Witter Supply Well: 17:SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Mtmicipal/Public ft. ft.
l ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R ft in
i
hidtistrial/Cominercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMP CE51E IETIIOD&AMOUNT
Non-Water Supply Well: (t. ft. /n
❑Monitoring ❑Recovery 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 ENIPI.ACE51ENT 51ET110D
❑Aquifer Test ❑Stonmvater Drainage ft. ff.
❑Experimental Technology ❑Subsidence Control ft. ft.
j ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color hardness soil/rock e, rain size,etc.)
ft. ft. C
4.Date Well(s)Completed: "�7-Z 2 Well ID# ft. ft.
5a.Well Location:
t 5;�C t�'foQert Y De-00-(e Mc4d' rt. n.
Facility/Owuer Name Facility ID9(if applcable) ft. f.
'7iq NDr+,-ern Fc-llS kL4. ft. ft.
Physical Address,City,and Zip ft. I ft.
v.'"I 21.REn1ARxs t.
u Parcel Identification No.(PIN)
l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell(�field, nne hit/long is sufficient) D ''J 1 22.Certifrca'
N -79' 31 4�. W
6.1s(are)the well(s): ®Permauent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby Geri jy that the trellis)a-as(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15ANCAC 02C.0100 or 15ANCAC 01C.0200)fell Construction Standards and that a cop),
if this is a repair,fill out known well construction it formation and explain the nature ofthe ofthis record has beenprovided to the it-ell owner.
repair under P21 rentarks section or on the back ofthis forin.
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. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
i
I 9.Total well depth below land surface: d Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
i Static water level below top of casing: 26 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1(unter level is above casing.use"+"
1.1.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR;Underground Injection Control(IUC)
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 roducin over 100,000 GPD: Copy to DWR,CCPCUA
j 13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Ralelg ,NC 27699-1611
13b.Disinfection type: HTH Amount: lb.
Fonn GW-l North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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