GW1-2023-00919_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use 0111y: - ®+�
1.Well Contractor Information: 1 A
l Landon Phillips 14.WATER ZONES
FRO51 TO I DESCRIPTION • �•� '
Well Contractor Name ft ft' r s'.c3st U
' 3441 A 12 5 a) t �t: rLn "'v
1 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licablc
NW Poole Well and Pump Company FROM -TO DIAMETER TtrICKNESS MATERIAL
1.,, ft. in. � .�
Company Name 1 �e
FROM
INNER CASING OR TUBING col her mal closed-loop)THICKNESS
2.Well Construction Permit N•_ /�/,°`(i..� 8�1 FRON TO DIAAfETER TIIICICNESS +MATERIAL
U.rt all applicable well coo.ra•uction pernrits(i.e.U1C,CotnrO•,Stare,Variance,etc.) ft. fL (rt•
ft. in•
3.Well Use(cheelt well use): ft,
Brauer Supply Well: 17.SCREEN ,
PP Y FROM _I TO D411tfETER SLOTS[ZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. I ft. in.
❑Geothermal(hlcating/Cooling Supply) Pkesidential Water Supply(single) ft. I ft. in.
f� ❑industrial/Commercial - ❑Residential Water Supply(shared) 18.GROUT
❑lrrl aLion ❑Wells>100,000 GPD FROM I TO NIATERIA EMPLACEMENTMETIIOD&ADIOUNT
Non-Water Supply Well: 0 ft. - ft. A41 • f(bi- v (IJ 4,00
i ❑ivlouiloring ❑Recovery ft. ft.
I Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
10.SAND/GRAVEL PACK If n lic:rlilc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO pIATERIAL EntPLACEntENTntCrilOD
❑Aquifer Test ❑StonmvaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach oddiNonal sheets If necessary)
j FROIt TO DESCRIPTION color,hardness,so)Urack type, rnin size,etc.)
❑Geotl)ennal(Ileating/Cooli»g Retunt) ❑Other(explain under#21 Remarks) ft. ft. �g9
j 1.Date Well(s)Completed: � ' Well ID# t ft. .J' tt. �. f f 4-1 ,
5n.Well Location: `{ / 9
e S' ft. K5' ft- .�/ L. 6&v
Facility/Owner Name Facility WM (ifopplicable) ft. ft. •
III plp•sica ddress,City,and Zip ft. ft.
_ t 21.REMARKS r-
4 ,t
County Parcel Identification No.(PIN) ' d d've =` sX trirl A-4, 7%
( 5b.Latitude and longitude in degrees/minutes/secouds or decimal degrees:
i (ifwell field,oneW/lo�ng is sufficient) �1 G� 22.Cerfr((Li�caatt'
j e Date r
6.Is(are)the well(s): ®Pernlaneut of ❑Temporary Signature of Certified\Yell Contractor _ -
By signing this fora,1 hereby certo,that lire+rell(s)eras(mere)constructed in accordance with
7.Is(his a repair to in existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 11'ell Construction Standards and that a cop),
\/'this is a repair,fill our knorn melt construction Information and erplain the nature ofthe ofthis record has beenprovided to the well omner.
I repair under P21 r•eurarks section or on the back ojthis form. 23.Site diagram or additional well details:
Ifi 3.nor Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well constniclion info
1 construction,only 1 GW-1 is heeded. Indicate TOTAL NUMBER of wells (add See Ovee in Remarks Box).You may also attach)additional pages if necessary.
i drilled: P 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdij)irenr(example-3Qn 200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below lop of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
j \looter level is above casing,use"+`"
(( 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
J 1.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 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 producinf:over 100,000 GPD:Copy to DWR,CCPCUA
'J BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
I3a.field(gpm) Method of test:
i i 13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019
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