GW1-2023-00953_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,-�
1.Well Contractor Information: e-
Landon PhIIIIpS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION ,
I 3441 A 14,5 ft 170
q7fft. Ir6it
NC Well Contractor Certification Number 15.OUTER CASING for mIiIN-case wells OR LINER if a licable.
NW Poole Well and Pump Company FROM TO DING
TIICKNESS MATERIAL
Company Name 1
f l ft. -7 ft. In. r Cr
.w .✓G
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I 16.INNER CASING OR TUBING eothermal closed-loop) '
'I 2.Well Construction Permit#: U Af- b 71�6I G`Zd2 2 FROM TO DIAMETER TIICKNESS MATERIAL
List all applicable yell construction permtits(i.e.UIC,County,State,Variance,etc.) ft. I ft. io.
3.Well Use(check well use): m I ft. In.
i, Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TIIICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(IIeating/Cooling Supply) Residential Water Supply(single) ft ft. Ira
❑hldustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
! ❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
I Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. tt.
i ❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control % ft.
❑Geotllennal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets If necessary)
i ❑Geotllennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. 1.TO ft. DESCRIPTION color,hardness,sailfrock e, rain sin etc.)
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4.Date Well(s)Cmnpleted: t7� 0 Z C Well ID# ft. 7 ft. G cif \l
II 5a.Well Location: ft. v Vt.
�r 5/G e J LL 5tt. ft.
jj Facility/Olvner Name ( / Facility ID#(ifopplicable) tr i ft. ft.
III r 13G G-��. .5' IBC/�m fl 7�� ��'J'r/�/ti ft. ft.
Physical Address,City,and Zip IV a 7sg'7 ft. ft.
C 21.REMARKS
` l.''L t.
f County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient) 22.Certificat'
N l ^ V W
f 6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contactor ¢ Date
Bysigning this fornt,I hereby certify that the vell(s)"'as(mere)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 If'ell Construction Standards and that a copy
/(this is a repair,fill out knouvt well construction information and explain the nature ofthe ofthis record has beenprovided no(lie well ouvter.
repair trader#21 remarks section or on the back ofthis form.
I 23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells(laving the 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v a (ft') Submit this GW-1 within 30 days of well completion per the following:
nor uuthiple hells list all depths Ifdii&renl(example-3@200'and 2@100)
I a d 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ'irater level is above casing,use"+'
1 24b.For Infection Wells:Copy to DWI Underground Injection Control(IUC)
1 11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
17..Well construction method: 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
IFOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
HTH 1 lb.
13b.Disinfection type: Amount:
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iForin GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 6-6-2018
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