GW1-2023-01030_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD(GW-1) For Inlemal Use Only: i
I.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Conlmclor Name FROM TO DFSCRIP"TION -
3441 A a36 `t' c2.35 `f a
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LiNER !f a llcnblc
NW Poole Well and Pump Company rROM TO UTAM1I,T.n THICKNESS MATERIAL
Company Naito ��
ft. ft. ' in,
"'!"GLLi/�•••!���� 16.1NNER CASING OR TUBING catirerrnnl closed-loon)
2.Well Construction Permit tt: r1toal To I DIAME'rlin THICKNESS I MATERIAL
List a!l applicable well corstrrrctlon peanuts 0.c.U1C,CrTunly,Stare,Irarlance,etc.) ft. S ft. / nr• ��' r�A _r
3,Well Use(cheep tVeil use): D. ✓ A.
Water Supply Well: 17.SCREEN
P Motif fL TO ft. DIAMETER: SLOTSIZE THICKNESS AtATEMAL
• ❑Agricultural ❑Munici al/Public
❑Geothermal(11caling/Cooling Supply) Residential Water Supply(single) ft. rt. In.
0Industrial/Commercial []Residential Water Supply(shared) 18.CROUT
❑irri ation ❑Wells>100,000GPD rnobl TO MATERIAL EMPLACEMENT alET110D&AMOUNT
Non-11'alcrSupply Well; ft. ft.
❑Monitoring ❑Recovery
Injection Well:
OA uifer Recharge ❑Groundwater Remediat_ion
❑Aquifer Storage and Recovery ❑Salinil Barrier 19.SAND/GRAVEL PACK If n licable
Y FROai TO MATERIAL EMPLACEMENTNIETIIOD
❑AquilbrTest OStonuwaterDrainage ft. ft.
❑LxperimealalTechnology 11OSubsidenceControl ft. ft.
❑Geolliennal(Closed Loop) ❑Tracer 20.DRILLING LOG laffach additionat sheets Irnecessa
OGeolhennal(Heating/Cooling Return) ❑Olher(explain under#21 Remarks) 17110111 t' DESCRB•'rlon color,hardness solUrock type.grilln size etc.
rt. rr. chi fL
4.Date Well(s)Completed: �a�� Well IDN ft. ft. /4
50.Well Location: n. a. le•Rr�.
Fncilil•!Owner Name ft. ft. L� ' t/.w
facility IDN(ifapplicable) w
_goZ I gc/ �3v�ri iris 2 �So� ��. �4 ��
ft. ft.
r-'
Physi nl A dress,City,and Zip l;fl , h�, ft. ft. a 3
21.REMARKS t '
. 'IItV Ul�1'i- ..•�l i 1.:'.57u'Jr..+ •
County Paiccl Identification No.(PIN)
is
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one laUlong is sufficient) f q i{t'•
bA E't , 22.Ccrtincat
N
f
�' 2 2 —2
6:Is(are)the well(s): IPPerninnent or.. ❑Temporary SignamreafCcnificd Well Contractor l Dille
By signing this fornt,I hereby cerllfj•that the irell(v)u•as(irere)constructed In accordance irirh
7.Is this a repair to an existing well: ❑Yds.t,or "UNu ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Ii'eU Cormtruction Standards and that a copy
1J•11ds is a repah•,fr11 out knun•n trell construction it fnruia!!on and explain the nature of the nfilds record has been prurlrled to the u•c11 corner.
repuir under 1121 reniar•kv section or of the back of this for r 1.
-'! 23.Site diagram or additional well,delails:
8.For Gcoprobe/DPT or Closed-Loop Geo(litirnhnl Wells having die same You may use the back of this page'lo provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Oven'in Remarks Box).You may also attach additional pages if necessary.
drilled: i
24.SUBMITTAL INSTRUCTIONS
9.Total well depth (below land surface: �+ ....,. ft.)
For ordrlple irefix list all depths Ifdbcrcw(ev aampld-3 00'an'd 2Q100'i Submit this GW-1 within 30 days of well completion per(lie following:
10.Stilic water level below laP cash 24a. For All Wells: Original forin to Division of Water Resources (DWR),
of '�i`}?�V
g''�" (ft.) information Processing Unit,1617 MSC,Raleigh,
!f t�'orer lcrel�is uGurc casing,use"�1•" i r;� h ,; � i g � NC 27699-I617 -
11.Borehole diameter: (in.) 24b.Tor Injection Wells-Copy tol•DWR, Underground hijection Control(IUC)
Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
1.e.2.nug11 construction method: Rotary
For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rosary,cable,direct pulls,ono,) county envirolunenlal health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: i
24d.For Water Wells producing over 100,000 GPD: Co to DWR,CCPCUA
^' " Blow Permit Pr Pro-gram,1611 MSC,Raleigh NC 27 99-1611 Copy
13a.YIeld(gpmj Method oftest:
13b.Disinfeclion'lype: HTH Amount: '
1 lb.
• .Fitt;, .';tti.;t �I . ,
Farm GW-1 NOAb Carolina Deparlurent ofEuviromnenlal Quality-Division of Water Resources I Revised 6-6-2018