GW1-2023-00942_Well Construction - GW1_20230120

WILL CONSTRUCTION RECORD(GW-1) For Internal Use only:a
1.Well Contractor Information: At 41
Landoll Phillips 14.WATER ZONES
Well Contractor Name \ FRO51 TO DESCRIPTION r
3441 A
a. D.
j NC Well Contractor Ccniftrntion Number
15.OUTER CASING for nruld-cased wells OR LINER If n t licnblc
1 NW Poole Well and Pump Company FROM TO DIA51ETElt TIIICICNESS MATERIAL
I ,G1,L) l�
Company Name1/
/� 16.INNER CASING OR TUBING eollierntal closed-loop)
2.Well Construction Permit#• F�d~C�6�7/� FROM TO DIAMETER I THICKNESS MATERIAL
l.isr nl/app!!r,•rrblc well casrlruaion permicr#.c.U/C,Cmauy,Slate,Variance,Cie.) ft. -ft.
3.Well Use.(cheep well use): ft. It.
Water Supply Well: 17.SCREEN
1711051 TO DIAMETER SLOTSIZE THICKNESS 111ATERL1L
❑Agricultural ❑Municipal/Public ft. n, ill.
❑Geothermal(Idcating/Cooling Supply) kesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri alion ❑Wells>100,000 GPD FRONT I TO MATERIAL F,n1PLACEMENTMETIIOD&ARIOUNT
i Non-Water Supply Well: H. L IZ�(� e ej
❑Monitoring ❑Recovery ft. ft.
In•jeclion Well:
❑Aquifer Recharge ❑Groundwater Itemedialion ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Darn 19.SAND/GRAVEL PACK if alicnblcer FROM TO MATERIAL I EMPLACEaIENTaIETIlOD
I� ❑Aquifcr'1•cst ❑Stornuvater Drainage ft. ft.
013%perimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) 01•racer 20.DRILLING LOG nilach nddltionnl streets irnecessn
❑Geolhennal(1-leating/Cooling Retum) ❑Oth FROM TO DESCItIrTIONcolor hardness sall/rack type, rain sin etc.)er(explain under N21 Remarks) ft- ft
�Ct i L
4.Date Well(s)Completed: 7iaz Z Well ID# ft. / ft. GL
in.Well Location: ft. G/
I • e cf.0 C v (c 10 .) h ft. ft.
I:acili Owner Name ,�Facility 1llN(iCapplicable) ft. ft.
l
i) /G 73 /u /U c S$F '-I 1"/or 'VC J 7Y k 2 rf. ff.
i� Physical Address,Cily,and Zip ft. ff.
N s h 21.REMARKS t
County Parcel Identification No.(PIN)
5b.Latitude and longitude In flegt•ces/nlintttes/seconds or decimal degrees:
(iflvell field,one I`nt/long is sufficient) 1 22.Cert'tftcat
•� l l l2- N _M i1 2 q 0 W 7 %3 e
I
6:Is(are)the well(s): Mllerninnent or ❑Temporilry Signature orCcnifled Well Contractor Date
'i Bysigning this form,1 hereby cent j•thal the we//(r)was(were)aonsirncted in accordance frith
II 7.Is this a repair to:111 existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 tile//Comawetion Standards and that a copy
!f this is a repair,fill our known trell coash•ircdon hrformatioa and explain ilia trawre of the of this record has been provided to the well owner.
repair under 1121 reinarkr section at,an[die back of this form. 23.Site diagram or additional we11 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
consliuction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
it drilled: i ( 24.SUBMITTAL INSTRUCTIONS
� 9.'lbfal well depth below Imld surface: l� (fl.)
Fornnr/dple+re//.r list all depths Ifrlocrem(asarnp1c-3« 00'and 2 rJ100') Submit this GW-I within 30 days of well completion per(he following:
10.Static water level below lop of casing: 2 (ft) 24n. For All Wells: Original Conn to Division of Water Resources (DWR),
l/'twarer lerel is above casing•use"•i•/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I1.Borehole diameter: t (ill•) 24b.For Injection Wells:Copy to DWR, Underground hljection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
i..nuger,Well construction cable, method: 24c.For Water Su
pplY.an"Open-Loop Geothermal Return Wells:Copy to the
(i.c.auger,rotary,cable,direct push cicJ county environnic5i l health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wclls rotlucin,over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gent) V Method of test BIOW lrennit Program,161]MSC,Ra elgh,NC 27699-161 I
131J.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmculal Quality-Division of Water Resources Revised 6-6-2018