GW1-2023-01035_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information:
Landon Phillips ,a:£WATER°:ZONES wf sF.W s..;
FROM TO DESCRIPTION
Well Contractor Name
3441 A c js .ft �SU n•
tt ft.
NC Well Contractor Certification Number =•15 OUrER.CASING.far mu164itiedwelle OR'1INERA(a' lieatile=
NW Poole Well and Pump Company FRO
Company Name M. TO DrAnri'rFR' THICKNESS 11fATERIAL
I ft. �G(V ft. �� 'm. tUZ ?R V
-
{ 1 INNER CASINO OR TUBING eothermal closed too` '
2.Well Construction Permit#: � ) �� FROM TO DIAMETER THICKNESS I MATERIAL -�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in. �k
3.Well Use(check well use): R' ft m _
17:SCREEN
: .•.
Water Supply Well: PROM TO DMIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in..
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft rn
❑Industrial/Commercial ?Residential Water Supply(shared) �+
❑Irri ation , ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&A51OUNT
Non-Water Supply Well: ft- ? e, ft. : dtle
❑Monitoring []Recovery fa ft.
Injection Well: ft. ft. ;
❑Aquifer Recharge ❑Groundwater Remediation
19.-SAND/GRAVEL PACK'(if. livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ; 09to inwaterDrainage
❑Experimental Technology ❑Subsidence Control ft ft l
r:
❑Geothermal(Closed Loop) ❑Tracer =20 DRILLING I OG attac6`addrhon`al`sheets if necessa '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION colon hardness soillrock type, rein sire,etc.)
ft. Z ft. i
f i ;
4.Date Well(s)Completed: J"�' Z _ We11ID# p� ft. it L) f4 + c f
Sa.Well Location: 100 ` 0 C ft, C 7,rn,4 l f
/ I it i
��191G/I ti L L ft. ft
i
Facility/Owner Name Facility ID#(if applicable) tL ft. - Y�
l�c�sw Ile /1 ft. ft. ;
Physical Address,City,and Zip ' I ft ft ft;�rtTf)r On f roC'x�d° lJ !l
I�11l�t 131?R$MARICS.i,i;;
Tf�/�1
County Parcel Identification No.(PIN) Used hardened steel drive shoe.
I
5b.Latitude and longitude in degrees/minutes%seeonds or decimal degrees: -
(ifwell field,one latlong is sufficient) Ljla 1 22.Certificati
`7S • -(9C17L�+ N W �-(a'_2Z_
6.Is(are)the well(s):'❑Permanent or ❑Temporary Srgnaiure ofCertified Well Contractor '. Date
Lp• ;ii By sikning this form,I hereby certify that,the rvell(s)ivas(were)constructed in accordarrcz with
7.Is this a repair to an existing well: OYes or ®No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We//Constnnction Standards and that a cea
If this is a repair,fill out known well construction infonnation and explain the nature of the of this record has been provided to the uiell ou ner.
repair carder#21 remarks section or on the back of this joriti' '
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobc,�PT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:+ a li,I i, t
24.SUBMITTAL INSTRUCTIONS
i.ld�sr.
9.Total well depth below land surface: 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple ivells list'all depths ifdfjerent(example-,3@200'acid 2@100')
10.Static water level below top of casing:•I`s -I ,�Ca (ft) 24a. For All Wells: Original form to Division of Water Resources (DAM.),
If water level is above casing,use"+" information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in, 246.For In,) ieetion 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 et,
(i.e.auger,rotary,cable,direct push,etc.) i county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY:` `;I " 24d.For Water Wells producin over 100,000 GPD:Copy to DWR,CCPCU
13a.Yield m It Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP )� I'
13b.Disinfection type: HTH Amount.• 1 Ib.
Form GW-1 i't North Carolina Department of Environmental Quality-Division of WaterResources i Revised 6-6-25 i