GW1-2023-01039_Well Construction - GW1_20230125

WELL CONSTRUCTdON RECORD fGW 11
For Internal Use Only: i -
1.Well Contractor Information:
Landon Phillips
14.WATER ZO
Well Contractor Name NESFROM TO DFSCRtP1'ION I
3441A 376 rr. •�s ft. fS t
NC Well CoutractorCertification Number ft. ft.
NW Poole Well and Pum 15.OUTER CASING for multi-cased wells OR LINER ;fn licnble
p Company FROM TO DJAMrrER t ; THCKNESS MATERIAL
Company Name If ii ". 1�c ft. 6 in.
2.Well Construction Permit#: 7 Q; 7f� 16•INNER CASING OR TUBING cothermal cloied-loon)
t
List all applicable well coilstnictlon perndls('.e.wL;;County,State,Variance,erc.J FROM ft. TO DIAMETER I. THICKNESS MATERIAL
ft. in
3.Well Use(check well use): I'
ft. it. in.
Water Supply Wcll: 17:SCREEN.
❑Agricultural ❑MunicipaUPublic FROM TO DIAh1ETER SLOTSILE THICKNESS M1iATERfAL
❑Geothermal(Healing/Coolin Su I ft
g Supply) Residential Water Supply(single)
❑Industrial/Commercial ft• fL in.
❑Residential Water Supply(shared)
❑]rri ation ❑Wells>100,000GPD 1gD�ROUT To Non-Water Supply Welt; //,�� MATERIAL ENII'LACEM1IEIYThIEfiiOD&AM1IOUNT
[:]Monitoring ❑Recovery V ft. (�
Ltjection Well: ft• ft. d'
[]Aquifer Recharge Groundwater Remediation (t• ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19•SAND/GRAVEL PACK ifa licabte
❑Aquifer Test ""'I'1 FROM TO h1ATE1UAL EMPLACEn1ENrhIETIIOD
OStomiwaterDrainage ft. fr.
❑.xperimcntal Technolo
gY OSubsidence Control ft. ft
❑Geothennal(Closed Loop) ❑Tracer
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/C'mlin Return) OOther(explain under#2l Remarks) FROM To DESCRII'1'fON corar,hnrdneas,soil/rock type, rain size,etc.
g
U fr. ft.
4.Date Well(s)Completed: a'3 0"Z P "
-�� Well IN fr. �� iG -
5a.Well Location: i j ft. �
Pacdity/OwncrNmnc Facility
ID#(ifapplicble)
]C5 •3Cb41Gnc� � ' ft
N 2
C. 7551 tt. ft. ��z3
Physical ddress;•City,end Zip '' t it.
11, ft. =.: ... .,:,.
fJ>^�
(,,I i�1�-"�,� 21.REMARI4S
CotmtY Parcel Identification Nc.(PM) Used hardened steel drive shoe.
5b.Latitude and longitude irr,degrees/minute's%seconds or decimal degrees:
(ihvell field,one laUlougrs'sulliciclit) '1 i 'li'1 Vi�'�:r;.�te„p',
3�P5, 22.Ccrtifrcad ,
N 1On Ut6 q, WL e W q
6.Is(nre)the wcll(s): ❑I'crmnncnt or ❑'fcmPorary Signattrrc ofCcrtificd Weil Contractor , _
! Date
7.Is this a repair toan existing nelL ❑Yes' 'ar' 7°JNp Uysigningdiisfo 1herebycertify that ibe.wells),teas(trerc)consbvaedbi accordance irith
irilds is a repalr,fill out knoten well constrtictlail inforatalion,and erplate the liatitre of the f tllISA NGcord 1 as bIC ¢n pro or ided to the II-el/alr c,rrell Caulnrctiai Standards and ihnr a copy
repair farrier 112/1'eutarkr section or oar the back of rlris farina`
I J 9' ' 23.Site diagram or additional well detil i 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'Sce Over,in Remarks Box).You may also attach additional pages ifnecessary.
drilled:+ 7"I
�S '
9.'Iptal well depth below land surface: 24.SUBMITTAL INSTRUCTIONS.. � / (ft)
Fa unilrrple Wells dsrall depths fdperen((example-,3Q200,'alid2@100') Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water Icvcl below top of casing: Z'',;(?q I (ft) 24a. For All Wells: Original form to Dill ision of Water Resources (DWR),
Iftratcr/evel is above caring,use'••I.^ Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
I1.Borehole diameter: 6 1.
(in.) 24b.For Iniection Wells: Copy to DWR, Underground Injection Control(IUC)
12.Well construction method; y
Rotar Program,1636 MSC,Raleigh,NC 27699-1636
i�;`;;;j' '.,
(i.e.auger,rotmy,.cable,dircctpush,etc.) 24e.For Water Supply and O3cri Loop Geoth11 ermal Return Wells Copy to the
county enetronmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: °." '
24d.For Water Wells mroducine over 100.00 GPD•Copy to DWR,CCI'CUA
13a.Yield(gpm) Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH
Yp . Amount:
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Fonn GW-I North Carolina Department ofEnvironmcntal Quality-Division of Water Resources
Revised 6.6-201.'