GW1-2023-01018_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD QW-1) For Internal Use only:
1.Well Contractor Information:
Landon Phillips ° y
rt,ee.+ 14,WATER ZONCS I i
Well Contractor Nome ��� 2023 FROM ft. TO ft. DUMPT10N
3441 A L LJ ' I
r n unh ft. It. i
NC Well ConlrnclorCcnificalion Number {{13f `1`a rSl I'fi`� +`
r at W 15.OUTER CASING for mull(-cased wells OR LINER if it dicnblc
fJW Poole Well and Pump Comb FROM TO DIAMETER; TIIICICNESS ARTERIAL
Company Name + fl fl. (r. In. `G d �Zcn�✓
( � 16.INNER CASING OR TUBING eothermnl closed-loo r "
2.(Yell Construction Permit N: 7((p I FROM To DIAMETER, I MATERIAL
list all applicable ive/1 constrrrclioa permits Ae.U/C,County,State,Parlance,etc.) ft. ft.
3,Well Use(cheep well use): ft. ft. in.
Water Supply Well: 17.SCREEN
P FROM ft. TO fly DLAAIETE" SLOTSIZE THICKNESS MATERIAL '
❑Agricullurol ❑lvlunici al/Public
❑Geothermal(Heating/Cooling Supply) Zesidential Water Supply(single) R ft in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rrl ation ❑Wells>100,000GPD MOAT TO MATE1l1AL EAIPLACEAIENT5lLT11OD&AA10UNT
Non-Water SupplyNilell: ft. a ft. I 2 OWE
❑Monitoring ❑Recovery ft. ft.
Injection Well;
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if n licable
❑Aquirer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EA1PLACE5IENTMET110D
❑AquilcrTcst ❑SlorinwaterDrainage fly ft.
❑Experimental Technology 6 I OSiibsidence Control
❑Gcolhermal(Closed Loop) I ;ti ❑'('racer 20.DRILLING LOG'attach additional sheets irnecessa
PROAI .TO DESCRU PION color,linreness solUrock type, rain sire etc.
❑Geothermal(Ileating/Cooling Return) ❑Other(explain under#21 Remarks) � fl d ft l' 1 ( .
C • c G
4.Dalc Wci1(s)Completed: b ' >'01' 22 Well IDN ft. _M, ft. C j
5a.Well Location: _ rt. Cl 6 f-ft. 2 e
e.
ft. 1
Facilil y/Owner Nonic ft. ft. !
Facility ID0(ifapplicable)
�� [o�C.i Qrl '� Cr•tiG�r. C 2210 3
Physical Address,City,and Zip'
21.REMARKS
'//L.t r•-L1 G nor ,.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ii'wcll field,one Int/long is sufficient)
22.Certilical'
C 6:ls(are)(lie well(s): (911eruimtent or . OTeinporar7y Signature ofCcrtifred Well Contractor Dole
By signing this forrn,I hereby cent f,that rife u•ell(r)u•as(were)constructed in accordance n•ith
7.Is this a repair to:i in existing well: ❑Yes;' or nNo 15A NCAC 02C.0100 or 1SA NCAC 02C.0200)Nell Consimcdon Standards and[liar a copy
1JYhis is a repair,fill our known well corisn•uction Iq/or•ina'0on'and erplahr the nairn•e of the afthis record has beery provided to the irell ou-ner.
repair under(121 reurarks section or oil die back ofthlsforn.
23.Site diagram or additional well details:
8.for Geoprobe/DPT or Closed-Loop Gcotlierinnl Wells having die same You may use the back of this page to provide additional well construction info
construction,only l GW-t is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �."o !r-
ft. �
For multiple irells list all depths ifd&rcut(eraarple-3 a 200 and 2 ac/00') ( ) Submit this GW-I Avithin 30 days of 1ecI1 completion per(lie following:
10.Sta tc water level below lop of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ry'uota/ere/is above cashrg,use ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: `� (ill,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
- Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:. r
(i.e.mi cr,cola 24c.For Water Su I and O cn-Loa Geothermal Return Wells:Copy to the
g ry,cable,direct pusli cto:) county envlrotunenlal heaitlI departmento the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over,100,000 GPD: Copy to DWR,CCPCUA
13a.Field ui Blow Penmt Program, 1611 MSC,Raleigh,NC 27699-1611
(6P ) Method of test:
I
13b.Disinfection(type: HTH Amount: 1 lb.
Form G%%l-1 Norili Carolina Deparlmenl ofEnvironnienlal Qunlily-Division of Waler.Resources I Rcviscd 6-6-2019