GW1-2023-01036_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: I'
1.Well Cori tractor Information:
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Landon Phillips
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14.WATER ZONES l
Well Contractor Name FR0 TO DESCRIrrION I
3441 A �� ft. /y s ft.
I �
NC Well Coilunctor Certification Number Sr ft' l ft' Gi
NW Poole Well and Pump Company 15.OUTER CASING for multi-cased wells OR LINER ifn licablc
FROM TO DtA11IETER I TincimSS MATERIAL
Company Name ft (Q r ft. t O of 5" 1 67.dv
8// 16:INNER CASING OR TUBING cathcrmal c1a aJ-lODD)
2.Well Construction Permit fl: to '�1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well caiisiniction perndrs(i.e.UiC,County,State,Yarfalice,etc.) ft @, in, '
3.Well Use(chaelr well use): ft. ft. in.
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1Vatcr Supply Well: 17:SCREEN.
❑Agricultural FROM TO DtAhtETER SLOTStLE THICKNESS MATERIAL
❑Municipal/Public ft.
❑Geothermal(Healing/Cooling Supply) /eesidential Water Supply sin
❑hrdustrial/Commercial y(single)
) ft•
OResidential Water Supply(shared)
❑lrri alion 18.GROUT
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEME1Yr 1 HOD&AhIOUMT
Non-FVatcr Supply Well: ft. do iL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquife'rRecharge ❑GroundwaterRemediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19..SAND/GRAVEL PACK ifs licabi
❑AquifcrTcst e
FROM TO MATERIAL Et13PLACEafENT11IETfIOD
,�` c❑StormwaterDrainage ft.
❑Experimental l'echnology ❑Subsidence Control
ft. ft.
❑GeOlhenmal(Closed Loop) ❑Tracer
20.DRILLING LOG nttseli ndditionnl sheets if necessa
❑Geothermal(He iting/Cooling Return). ❑Other(ex lain under#21 Remarks) rRoM TO DEseR7rrtoN color,6nrdness,soil/rock t• e,grnill alto,cic.
J ft. tT ft. 1U S.
4.Date Well(s)Completed: -Z Z Well IDY a fr. _e) M -
5a.Well Location: :r
d s n: CfGR,I eP.,
7✓'r �i�/L��i, If' t.rl',,ri'i E. ft. ft.
racility/�OwncrNamc racilityIDY(ifepplicable) ft. ft. JAN .2 5 2023
"T /T' idr/✓�%r J�/ G�G'/ !OU[f�� r ft. rt.
Physical Address,City,mid Zip o} ;,.. i
__ ✓Gin '.�/S( 21.REMARI f t I•%tt�alQ.Jc�i.0G W
County Parcel Identification No.(PEN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/se'coriifs or decimal degrees:
(ifwcll field,one lat/long is sufficient). •I•!pi :I;L kL;)5j.1 1
22.Certificad ,
J-j- N
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6.Is(nre)the wcll(s): dl'crmanent or ❑Temporary Signature ofCcrtificd Wcll Contractor l A 13 �e "
Date
.•."' BY signing ddsforni,!hereby certify that ilia.,rell(s)was(were)constructed in accordance with
7.Is this n repair loan existing well: OYes of" 19No ISA NGIC 01C.0i00 or ISA NCAC 02C.0200/Yell COMI-ctiou Standards and that a con,,
/fthis is a repair,fill out known well consinictiort irrfortrration acid explain the eature ofthe ofdds record hat been provided ro the well oiriler.
repair under 021 remark section or oil the back of th joriil. "'
23.Site diagram or additional well details:
8.For G cop robe/DPT or Closed-Loop GeothermAl Wells having die 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'Sce Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:..,
Iin; 24.SUBMITTAL INSTRUCTIONS
9. !blot well depth below land surface: O�o�Fo (ft)
riini%tiple,rellslislalldeplhsffd�erenr'(example-3rei200'',bird2Q100') Submit this GW-I within 30 days ofwell completion per the following:
10.Static water level below top of ca irig: ;2•iG 24a. For All Wells: Original form to Di i vision of Water Resources (DIVR),
Ifiraierlevel is above casing,use"-F" (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWRJ Underground Injection Control(IUC)
Rota Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ry ,
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Winter Supply and Onen-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:'
3 24d.For Water Wells producing over 100 000 GI'D-Copy to DWR,CCPCUA
I3a.Yield(gpm) llict)tod of test: BLOW Fermat Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH !:'.•!.�•,Ib
Amount: j
. • I.i;:,ill i ., I I`,.�:911 l„ - i
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Porn G1V-1 I !INorth Carolina Department ofEnvironmcatal
la Quality Division of Water Resources I
Revised 6.6-2013