GW1-2023-01032_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips g'IawnTER'zoNEs
Well Contractor Name FROM TO I DESCRIPTION
3441 A G
NC Well Contractor Certification Number I5GOUTER'.CASING f6r':niultica5ed.welis'O LINER ifa licabfe
NW Poole Well and Pump Company FROM T DIAMETER THICKNESS MATERIAL
Company Name �a fit. ft. [ in 1 Jar AL V
_'I GINNER' SING OR-TUBING' 'eothe msl-closed.loo'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,era) ft. ft. in
3.Well Use(check well use): ft. ft.
Water Supply Well: 1.7siSCREEN ;;r
rROM I TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural 1*unicipal/Public ft. ft. is
❑Geothennal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) a'18 GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt ft.
❑Monitoring []Recovery ft. ft.
Injection Well:
fit. fit.
❑Aquifer Recharge ❑Groundwater Remediationi9:;SAND/GRAVEI3PACK if.ti"'licable.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I fL ft.
❑Aquifer Test '' J I d 4 ;1,❑Stormwater Drainage
❑Experimental Technology i ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,'DRILt)ING%0G.attich:additionalsheets ifneceIMi '.
❑Geothenmal(Heating/Cooling Return)-,:..❑Other(explain under#21 Remarks FROM To DEscRSIION croon hardness,soiVrockt e, min size,etc.
fit. fit.
�_�a as o � ' �.
4.Date Well(s)Completed: Well ID# ft. ft. S11r11 1.
5a.Well Location: h :, ru, ( ft. s"ft. tt p,,V � T
030fR ?D) ft. fL
._
Facility/Owner Name Facility ID#(if applicable) ft. ft
,F0rATry ft. ft. AN 2
Physical Address,
City,and Zip ''° 46IN4O yke/t NC 7�� ft. ft. ^
r I'rl/.
ar,� n•
County Parcel Identification No.(PIN) Used hardened steel drive shod�C}t'�if.�t� !
5b.Latitude and longitude in degrees/minnti e'Aeconds or decimal degrees:
(if well field,one lat/long is sufficient) °l: ,..•: 22.Certifrcati
?//
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
C 1 ; By signing this form,I hereby certify that due well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No ISA NCAC 01C.0100 or 15A NCAC 02C.0200 Arell Construction Standards and that a copy
If this is a repair,fill out known well construction Information and explain the nature of the of this record has been provided to the well o++ner.
repair under 921 remarks section or or the back of dds farm.
. ,• i, 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:+
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �® (fit)
For multiple wells list all dept/is if differeni(example=`3Q206'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
I .,, ,I i'
;':: ;i;; U ft 24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing:I:' V ( ) Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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,rot
ary,cable,direct push,etc,)I county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:J" i'' 24d.For Water Wells producing over 100,000 GPD:Co to DWR,CCFCUA
(jam i,,, si JA�,rI I. PY
13a.Yield m /�/ Method of test: BLOW Permit Program,1611 MSC,Raleigh;NC 27699-1611
(gP )
13b.Disinfection type: I"1TF 1 Amount: 1 lb.
Form GW-1 i. T,North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201g