GW1-2023-01042_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD (GW-1) For Internal Use—Only:-
1.Well Contractor Information: i
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3.441 A 5 ft. b ft. t0/11%
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER ilop Iicnble
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS pIATERtAr
Company Name ft. 4 ft 1 1 in.' -
I6.IN ER CASING OR TUNING eothermal closed-loon)tJ
2.Well Construction Permit{l: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable+roll construction permits(i.e.UIC.County,State,Variance,etc.) ft. ft, in
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3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
❑A riclrllUral oM TO DIAMETER SLOTSIZE TIIICKNFSS MATERIAL
g ❑Municipal/Public ft. /414 r L ;n
❑Geothennal(Healing/Cooling Supply) }Residential Water Supply(single) o Z Gti
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18..GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT MEniOD&A6IOUNT
Non-Water Supply Well: fL ft.
❑Monitoring ❑Recovery rr rr.
Injection Well:
❑A uifer Recharge ft. ft.
q g ❑GroundwatcrRemediation
❑Aquifer Storage and Recove 19.SAND/GRAVEL PACK Ifa licable
ty ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENrnTMIOD
❑Aquifer Test ; . ❑StdnnwatcrDrainage rt• le��
[7L'xperimental Technology ❑Subsidence Control
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG nttaclt additional It acts if necessa
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under921 Remarks FROM TO DESCwrrrON color6nrdacse,son/rock type, abtsire,etc.
ft. ft.
4.Date Well(s)Completed:ILL?. Z Well IDa ft. ra �
Sa.Well Location: tt. ft.
Lc,, L r y 13D
ft. ft.
_-
Ficility/Owner Name Facility IDII(ifapplirable) ft. ft. o
�•�D �11____�_q�W ,'�o t1n�:��y�I�C NC �759� ft. rt.
Physical Address,City,and Zip """ ft. ft.
7
'rrc.,\ I A 21.REMARKS
County Parcel Identification No.(PIN) Used hardened Steel drive:W6QJrj6& •
,5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one ladlong is sutlicient) ji22.CCrtificati
zz
6.Is(are)the wcll(s): ❑Permanent or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing this form,I hereby certify that tho.u,ell(s)was(were)constructed in accordance with
7.Is this a repnir to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or ISA NCAC 02C.600'Ifre11 Constrrctton Standarris and Ihat a copy
If this Ir a repair,fill out known+veil construction iI jorination and explain the nature of the of this record has been provided to the well of ner:
repair under I121 remorkr section or or the back of dds,jornh.I
23.Site dingram or additional well details:
8.For Geopr•obe/DPT or Closed-Loop Geotliermal,Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:+
24.SUBMITTAL INSTRUCTIONS
9•Total well depth below land surface:
FoI•hrtultiple wells list all depths ifdifjeretit(example-3@200'and 2©100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:' Pt; 2b (ft) 24a. For All Wells: Original form tl Division of Water Resources (DWR),
!'+rater/evel is above casing;use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I.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 - 1
(i.e.anger,rotary,cable,direct pusit,etc,) 24c.For Water Supply and Oven-Loon Geothermal Return Wells:Copy to the
county environmental health departmenVof the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over.'100 000 GPD Copy to DWR,CCPCUn
(gP ) Method of test:
13a.Yield rn BLOW PerautProgram, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: HTH Amount: 1 Ib.
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ITonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018