GW1-2023-00949_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .,
� 1.1Vc11 Contractor Information: 41v n f
Landon Phillips 14.WATER ZONES
. _ FROM TO DESCRIPTION
\'.'cllContractor Nama ft. ft. �•;*• -"wt�
NC Well Contractor Certification Number 15.OUTER CASING for multi--cased wells OR LINER if n licablc
f NW Poole Well and Pump Company FROM To DIAM1IETER TIIICI{NESS MATERIAL ^
{[^r ft. ft. In.
Company Nau,c
16.INNER CASING OR TUDING fizeilthercard closed-loop)
�G
2.Well Construction Permit#: .��r,✓ -y�C1� ' ac)r r•Itom i To I nlnnlE•rEn I TIucI{NEss I nlnTEnlnL
Licr all applicable well canru rrcrion perudls(l.e.UIC,Connly,State,{variance,etc.) ft. ft. in.
I ft. ft.3.Well Use(check well use): in.
Water Supply Well: 17.SCREEN
- FROM TO DIAMETER SLOTSIZE TillCKNF.SS MATERIAL '
❑Agricultural ❑ uniclpal/Public ft. n. in.
❑Geothermal(1-leating/Cooling Supply) edential Water Supply(single) fr. ft. in.
I
❑Industrial/Commercial `❑Residential Water Supply share pp y(shared)) 18.GROUT
❑kri ation 0Wells>100,000GPD 17111051 1 TO MATERIAL EMPLACEM1IENT51ETHOD&MlouN'r
Non-Water Supply Well: (j ft. � it. 1 �c �.f-
❑Monitoring ❑Recovery ft. ft.
i Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I En1PLACEMENTMETHOD
i ❑AquifcrTcst ❑StornlwaterDrainage ft. ':2, ft.
II ❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) 07Yacer 20.DRILLING LOG nitach additional skcels irnecessn
❑Geothermal(1-leating/Cooling Return) ❑Other(explain under 421 Remarks) MOMro DFscitn''r1oN color,karaneaa aoivrock type,grain size etc.)
/� ft. ft. t9. 5, a.,
4.Dale Well(s)Completed:(0-1(9=as)` Well ID/f tt. tt. c`G'.
5a.Well Location: ft. �(')ft.
- F � ft. ft.
`,IV , 1 k e� s' J LlY'
Facility/Owner Nan�ic I ) Facility IDDM(ifapplicable) ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS t
i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeshnhn ites/seconds or decimal degrees:
(iirrjwell Geld,one Ia
n/lo
ng is sufficient) ` 22.Certifnent•
N &I- V LJ�J W l,e llfi �.
6:Is(are)the well(s): ®Pernlnnent or ❑Temporary Signature ofCertificd Well Contractor ` Date
i Dysigning this fornn,I hereby certify that the u•ell(s)Bras(were)cotnsimcled in accordance,rich
7.Is this a repair to all existing well: ❑Yes or MNo 15A NCAC 01C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a copy
1 1J71tis is a repair,fill an kno,rn well construction igrorniation and explain the nature of the oflhis record has been provided to the ire/l ouver.
repair under 1121 remorks section or on the back of this form.
l 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welds leaving the same You may use the back of this page to provide additional well construction info
j construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
II drilled: a 24,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (] S (ft.) Submit this GW-I within 30 days of well completion per the following:
Fa•nudtiple,re/Ls list all depths!/di/ferew(example-3@200'and 1@100)
V ft 24n. For All Wells. Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!/'unrcrcrlcrells nborc casting,use"�i"
i 11.Borehole diameter: (in,) 24b.For Injection Welts:Copy to DWR,Underground Leection Control(IUC)
i Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where mstalled
FOR NYATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:_Copy to DWR,CCPCUA
BIOW Permit Program,1G11 MSC,Raleigh,NC 27699-1611
13%Yield(gpnr) . c) Method of test:
HTH 1 lb.
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resource I s Revised 6.6-2018
1 •