GW1-2023-00917_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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l 1.Well Contractor Information: JAN 9 ')
Landon Phillips 14.1VATERZONES
I FROM D �10�
Well ^0 ft. ft. /O '1
ti1Qi21
0G o
3441 A O
/ #rt. �g ft.
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased wells OR LINER if a dicoble
I NW Poole Well and Pump Company FROa1 TO DIAIIIETEII TrCKNESS MATERIAL
I .r ft. illrt. .AM- G.41
Company Name
' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' /� t1� 2S FROM TO DIAMETER THICKNESS MATERIAL
Gist all applicable yell const uctlon permits(i.e.UIC,County,State,Ifarlance,etc.) ft. ft.
3.Well Use(cheelt well use): ft. ft. in.
i Water Supply Well: 17.SCREEN ,
pp Y MGM TO DIAMETER SLOTSIZE THICKNESS AIATERiAL
❑Agricultural ❑Municipal/Public R, ft. is
❑Geothermal(Iieating/Cooling Supply) ❑Residential Water Supply(single) fL H,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
Irrl ation ❑Wells>100000GPD FROnt I TO NIATERIAL Et1IPLACEIIIENTl11ETHOD@AMOUNT
Non-Water Supply Well: 0 11' Aq fr' ;N 6N t%k OK Q��
❑Monitoring ❑Recovery fr. ft.
i Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Relmediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FR051 TO MATERIAL EhIPLACEnIENTMETIIOD
❑Aquifer Test ❑StorinwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. A.
i ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheers If necessa )
Moat TO DESCRII'T10N color,hardness,soillrac)t h•e, min size etc-)
❑Geothermal(IIeating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. .2 ft' ,So i L
1.Date Well(s)Completed: - 0'a Well ID# a ft, O a ft. A vP S C ZA'
5a.Well Location: 65 tt. w"IT
�(1�2 0-ab D�L1C/S�RS'rl NC. ft. ft.
Pacitily/Owner Name Facility ID11(if applicable)
ft. ft.
2g /{l6�SAND2►� �R. ft. rt.
'! Physical Address,City,and Zip ft. ft.
j HAIS i 0.� 21.REMARKS
Ga
iCounty Parcel Identification No.(PIN)
51).Latilude rind longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaVt�ojn�g is sufficient) 22.Ccrl49
ific if
i Signature of:IS(arC)th O'e C11(s): ®Permanent or ❑Temporary Certified Well Contractor Date
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By signing this form,I hereby certify that the wells)u•as(mere)constructed in accordance with
7.Is this a repair form existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
1/'lhis Is a repair,fill out kntnrn ire/l construction it formation and explain ilia nature ofthe ofthis retard has been provided to die well owner.
repair under#21 reniarks section m•rat the back of dds form.
23.Site diagram or additional well 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over In Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24,SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: Ja}yy•5^ (ft') Submit this GW-1 within 30 clays ofwell completion per the following:
For a ihiple wells list all depths tf dij9erent(example-3 rt 200'and 2@100)
1 24a. For All Wells: Original font to Division of Water Resources (DWR),
10.Static water level below lop of casing: o`U (ft.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifirater level is above casing,use
j11.Borehole diameter: 6 (ID.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(rUC)
1 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.muger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY NVELLS.ONLY: 24d.For Water\Yells producing over"0,000 GPD: Copy to DWR,CCPCUA
i BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpnn) 0 Method of test:
t 13b.Disinfection type: HTH Amount: 1 lb. ,
Forns GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018
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