GW1-2023-00918_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use ODIy: +�
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1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Conlmclor Name FROM TO DFSCRIPTION 3441 A -
a2 S rt' 2 b ft' o! In G�+
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NC Well Contractor Certification Number 15.OUTER CASING for mulct-mse wells 0 t LINER if n licablc
NW Poole Well and Pump Company FROM TO DIAh ETER T1IICILNESS MATERIAL
ft 4
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Company Name
i I - I _715f�d-
16.INNER CASING OR TUBING colherranl closed-loop)
i 2.Well Construction Permit N' I O FROM TO DIAhIE'rEll THICKNESS AIA' RIAL
List all applicable sell constr•action permits 0. .UIG County,State,Mariaace•etc.)
3.Well Use(cheep well use): ft. ft. in.
Witter Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSI'LE I THICKNESS MATERIAL
❑Agricultural 6 ❑Municipal/Public ft. n. in.
❑Geolhernnal(1-leating/Cooling Supply) MZesidential Water Supply(single)
I ❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
❑Irri anon ❑Wells>100,000GPll FIIOMI TO NIA9'EIIIAL EMPLACEM1IENTMETiIOD&AM1IOUNT
Nou-\Pater Supply Well: rt. ft. e0 .,
❑Monitoring ❑Recovery
! Injection Well: ff. ft.
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GItAVELPACK ifn, licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M1IATLIUAL I EMPLACEQIENTh1ETROD
❑Aquiibr'I'cst ❑StornnvaterDrainage
ElExperimenlal Technology ❑Subsidence Control
❑Geolliennal(Closed Loop) 01'racer 20.DRILLING LOG alfach addltionnl sleets irnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under H21 Remarks) FROM To DESCRIPTION color hirdnesso soillracktype,grilin size etc.
ft. ft. e
! 4.Date Well(s)Completed:7- 22 WeII 1DH ft.
Sa.Well Location:
qr,_,4A iL%#
II t•a�cciiillhylO,vnerr Naul�c J f��,/ /� .�(.�/�Facility ID'U(ifapplicable) ft. ft.
{ 111 ! e—Verly ! )K )OL;e_ 041cs /V G ft. ft.
Physical Address,City,and Zip a 7S
�O� �^ 21.REMARKS r
County I Parcel Idctuification No.(PIN)
Sb.Lalitude:md longitude in degrees/minutes/secw,ds or decimal degrees:
(il'well field,one InUlong is sufficient) J 22.Certificat'
6:Is(are)(lie well(s): OPerluanent or ❑Temporary Signature ofCcrlifed Well Contractor ` Date
OF signing this form,I hereby cerilry that the well(i)u-as(were)constructers in accordance with
+ 7.Is this a repair to an existing well: ❑Yes or TiNo 15A NCIIC 01C.0100 or ISA NCAC 02C.0200 We/l Consinrction Standards anrs that a cliff
1 /f This is a repair,fill out kao+rn well construction in/braration and a plain the nature of/he nfilds record has been provided to the srel/ou-ner.
repair under 1111 remarks section or•on the back of this form.
23.Site diagram or additional well details:
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
c01151RIC6011,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: t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below hand surface: SOS (fl.) Submit this GW-1 within 30 days of well completion per the following:
l.'or nndnple orelis list all depths lfdijjcrcnt(arrrrnple-3 tCi 100'and 1 a 100')
0.Slnlic svnter level below lop of easing �� (fl) 24% For All Wells: Original form to Division of Water Resources (DWR),
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Slt-Icrel is n l e casing,use•''�'! information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1D (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
! Rotary Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
Ox.nugcr,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY; 24d.For Water Wclls roducin over I00 000 GPD:Copy to DWR,CCPCUA
BIOW 1'ennd Program,1611 MSC,Ra e t' NC 27699-IGl 1
On.Yield(gpn) O D•lethod of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmonlol Quality-Division of Water Resources Rcviscd 6.6-2018
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