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HomeMy WebLinkAboutGW1-2023-00942_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