GW1-2023-00943_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Jq At 9
Landon Phillips - '
14.WATER ZONES �
FROM TO DESCRIPTION �+%1
\i'cllContmctorName ft. ft. �.;` ^"�^�:•.
3441 A /h
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 lllAp1ETEl. THICKNESS MATERIAL
ft. 6 2 ft. in. Jgf{ 1
Company Name �+
2 IG. NNER CASING OR TUBING cotlter»tal closed-loop)
2.Well Construction Permit#• Y v l _D � FR011I TO DIAMETER I THICKNESS I MATERIAL
Idst all applicable well construction permits(i.a.UIC,Counly,State,Madame,etc.) Ct. ft. in.
3.Well Use(check well use): rr. ft. is
Water Supply Well: 17.FROMSCREE TO DIAa1L•TER SLOT SIZE THICKNESS aATERIAL '
❑Agricultural ❑Municipal/Public ft. ft. ;n•
OGeothennal(1-leating/Cooling Supply) Residential Water Supply(single) ft. ft. ia•
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL ERIPLACE51ENT METHOD&AMOUNT
Non-Water Supply Well: O ft. C20 ft. OIC V
❑Monitoring ❑Recovery ft. ft.
i Injection Well:
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTMETIIOD
❑AquilbrTrst ❑StornwaterDrainage ft. fr.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑•I'racer 20.DRILLING LOG attach additionnl sheets if necessary)
rROa1 TO DESCRIPTION color,hardness sof(rock type, nun sin etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. ft. It G
` 4.Dale Well(s)Completed: _ T2 Well ID/1 a ft. ft. C
5a.Well Location: S7
' ft• 4QR ft.
i Loyd bo, f S
FacilQiliily/Ow/n'ergName y� {�►►yy�� Pacility ID#(if applicable) ft. ft.
(ybWt1 jt ll ( JtJ C ft. ft.
Physical Address,City,and Zip J 75 ft. ft.
co i 21.RE51ARiCS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if%vell field,one lat/long is sufficient) t 22.CertifiC,t'
N 71°0 [D- 79 W -17-2 z
6.Is(are)life well(s): ®Perninneut or ❑Temporary Signature ofCertified Well Contractor ` Data
By signing this form,I hereby cert j•that ilia well(r)Bras(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consinncilon Standards and that a copy
1j'this is a repair,fill out known ire//construction hiforntatio n and explain Ilia nature of the afthis record has been pros hied to Ilse me/l ouner.
repair under 1121 remarks section or on Ilse back oftbis form.
23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having Ole 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: r 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 ifd1jjerenr(eranplc-3 a 200'and l rt 100')
24a. For All Wells: Original forth to Division of Water Resources (DWR),
i 10.Static water level below top of casing: (ft.) lnfbrri�ation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ihrater lanai is abort cnsing,use
11.Borehole diameter: (in.) 24b.For Injection 1Vells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction Inetliod: 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 SUPPL WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpnl) � Method of test: 1310W Permit Program,1G11 MSC,Raleigh,NC 27699-1611
� 13b.Disinfection type: HTH Amount: 1 lb.
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Porn GW-I North Carolina Dcparhnenl of Ettvirorunental Quality-Division of Water Resources Revised 6-6-20I8
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