GW1-2023-01033_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips i14:wATER'Z0NEs _ .s•'.
We1lContractorName FROM TO DESCRIPTION ft.
3441 A S- rt. ��;
rt. ft.
NC Well Contractor Certification Number 15�OUTER2VASING`for:riiulti ca3ed wells:OR-LINER if d IicAble=
NW Poole Well and Pump Company EOM TO D Tm+ T>IrclavEss MATERIAL
ft ft. C� a j�,,
Company Name :1 a,.
6 R
Z .:1NNE CASING RfiU OBING `eotheiriiei closed-loo -
2.Well Construction,Permit#: l / 7 J FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fA ft
3.Well Use(check well use): m ft.
in.
Water Supply Well:
FROM TO DIAMETER SLOT SUE TffiCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) t
❑Irri ation ❑Wells>100,000 GPD FROM TO~ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -0 ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
it. ft, i
❑Aquifer Recharge ❑Groundwater Remediation
,19:SAND/GRAl!Eli'PACIC(if a`lict+bleZi
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test. + I' .l!r I�I'�II��f75toimwaterDrainage to ft
❑Experimental Technology, ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 2di 1RILI9ING.'.'IiOG'attach i ddiiionil sheets ifuecessa
❑Geothermal Heating/Cooling Return ❑Other(explain under 921 Remarks FROM TO DE�CRIPI'ION rotor,naraaess sail/rocka sin size,etc.
o ft. a ft. i d SY
4.Date Well(s)Completed:A-13'ZZ Wel1IDN ft. to �.a•
5a.Well Location:`` - a fa 6—
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
ft. ft. N 5 2Q23
Physical Address,134,and Zip' ' .,t i, r;,„, ft. ft.
�'+ r /�' •21.REMARI4S .� ._ �v•..•.;,. ,;
County t: Parcel Identification No.(PIN) Used hardened steel drive shoe u
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwwellrfield,one lat/long is sufficient)'.„ �;r'•i1,'I+ 22.Certificati
6.Is(are)the well(s): ❑Permanent or OTemporary Srgnahue ofCartified Well Contractor; Date
..i By signing this form,I hereby certify that the well(s)was(were)consmrcied in accordance widt
7.Is this a repair.. to an existing well: l7Ycs or nNo ISA NCAC 01C.0100 or 15A NCAC 0IC.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infotination and explain the nature of the of this record has been provided to the'well ou ner.
repair under#21 remarks section or on the back qjtki form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:n I l,-t',UI?S
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S (ft)
Submit this GW-1 within 30 days of well completionper the following:
Fo•multiple wells'lis(all depths ifd�erent;(example-'3 atw�00'attd 2(a)100') ,
:-. p', 24a. For All Wells: Original form to Division of Water Resources (DWR);
10.Static water level below toplof,casirig:s° (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ;
11.Borehole diameter: 6 G (in.) 24b.For Injection Wells: Copy to DWR Underground Injection Control(IUC)
r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary I
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
FOR WATER SUPPLY W)LLS*ONLTr r'•1 ' ' 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
�
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 i In 1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018