GW1-2023-01031_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD (GW-1) For Inte/rnal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
a ft. ,- rt. 3
3441 A of rt. d-8 rt.
NC Well Contmclor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if n likable
NW Poole Well and Pump Company mom TO DIAMETER THIC'NEss MATERIAL
Company Name i •dyi 5.2 IV
J p 16.INNER CASING OR TUBING eoiliermal closed-loop)
2.Well Construction Permit#: [ v ! .3 a MOM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction pernrlls fli.e.UIC,Cowl%State,Varlanrce,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
FROM TO DIAMETER SLOTSrLE TIQCKNFSS MATOIAL
❑Agricultural ❑MunicipaVPublic 0 ft. 3 0 T_ft. 6 f in• .UZ S Pvc
❑Geothermal(Healing/Cooling Supply) sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
❑Irri alien ❑Wells>100,000 GPD FR0111 TO MATERIAL EMPLACEMENT MEMOD&AMOUNT
Non-Watcr Supply Well: Q ft. Zv ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StorrnwaterDrainagc 0ft• 3 C) ,
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothernal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(l•Icating/Cooling Return) TO DESCRIPTION color,hardness,soil/rock) krain site,etc.) ❑Other(explain under#21 Remarks) ft.
/
4.Date Well(s)Completed: -�^'z Z Well ID# a ft SU fL C�A
5a.Well Location: S(J it. 30i n, f + I
SPA rn i n ft. ft.
"t
Facility/Orvrtcr Name � Facility 1DA(ifapplirable) ft. ft. ,
ft. ft. '
Co?s2 (d iAdr, ,,,>r I�:( ; ldutf�,..� 202�
Physical Address,City,and Zip ft, ft• ln1 Vr f::,..+ - ,.>>
21.REMARKS ��. ..d....•.:y .r,
County parcel identification Na.(PIN) .
nty tG�/� Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field,one Willingis sufficient) (/ ,lJ 22.Certitieati
dJ�GI N q W _
6.Is(nrc)(lie well(s): ❑Permanent or ❑'Temporary Signature ofCcrtificd Well Contractor Dale
fly signing this form,l hereby certify that tha well(s)uvas(here)constructed in accordance iridl
7.Is this a repair to an existing well: ❑Yes "or ,MNo ISA NCAC 02C.0100 or 15A NCAC 01C.0100 li'ell Corstntction Standards and that a copy
If this•is a repair fill out knorn well constriction lnformation and erplaht lire nature of the of this record has been provided to ilia well au•ner.
repair under 1121 remarks section or on lire back of this fora;.
..
I,i, 23.Site diagram or additional well details:
8.For Geopr•obe/DPT or Closed-Loop GeothcrMnl,Wells having the same You may use the back of this page to.provide additional well construction info
construction,only 1 GW-I 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: ft.
For rnndtiple wells list all depths ifdr(jerem(example-3 ref 100'and 1©100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z Q ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijuarer larval Is above casing,use"i" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
) 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,arc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method oftcst:
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
•
13b.Aisinfectiou type: HTH Amount: 1 Ib.
Fomt GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources j Revised 6-6-201.'