GW1-2023-01043_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
n14 WATER;ZONES ';> J:
Well Contractor Name FROM TO DEs R moN
3441 A 4W ft. 3Ar ft. p
ft. ft.
NC Well Contractor Certification Number 715 OUTER CASIPIG foimidh-cased;ivells'OR LINER if n' licable
NW Poole Well and Pump Company FROM TO DIAMETER THICIINESS MATERIAL
Company Name 4/ ft ?� it in. eCCjd s �~Et�l.'
��-` r16llUlVE$.CASING•ORTUBING' eotherm®!:closed-loo" ."
2.Well Construction Permit#: Joe FROM I TO I DLUVMTER I THmCKNEss MATERIAL
List all applicable Nell construction permits ri.e.UIC,Coun(p,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
;:17 SCREEN",.
Water Supply Well: FROM I TO I DIA IM7R' I SLOTS17F I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public fn ft. in.
❑Geothennal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
[]Irrigation ❑Wells>100,000 GPD FROM TO MATEffinL EMPLACEMENT n19MOD&AbIOUrff
Non-Water.Supply Well: 0it it.
❑Monitoring ❑Recovery. - ft. ft.
Injection Well:
ft.
❑Aquifer Recharge ❑Groundwater Remediation it.
A9t:SAND/.GRAVEIIPACK ifa•`licafile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To nATERIAL I EMPLACEMENT METHOD
❑Aquifer Test !! �!, IDStoimwaterDrainage ft. ft.
❑Experimental Technology []Subsidence Control ft. ft.
❑ got temtal(Closed Loop) ❑Tracer 10RDRI1iING.1L0G tittsch nddiiiooafsheeis ifnecessa . :: •` '
❑Geothermal(IIeating/Cooling Retum ❑Other(ex lain under#21 Remarks FROM TO DESCRIMON color,hardness,soWrock a ain size,etc
0 ft. Z it. fG' 's
4.Date Well(s)Completed: �fl-2� Well ID# ft. (J ft.
5a.Well Location: , n( &o ft. C'S." ft. C�J✓G;�1 t.��
!(IGt/G/ei� ,; fa ft
Facili4/0wncr Name 62
� / Facility ID#(if applicable) ft. ft. ®'
1023
7-0 �In& 62(Cl'( a '��C! Iwloi) ✓11 , ft. ft. e�
Physical Address,City,and eip ft. ft. i
21 REMARKS:.' ; ;, �^
County Parcel Identification No.(PIN)
Used hardened steel drive shoe,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient);- I:1111 is;i• 22.Certificati
I
W Z©
6.Is(arc)the weli(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor j, Date
By signing this form,I hereby certify that}he wells)bras(were)constructed in accordance with
7.Is this a repair to an existing well: ❑'Yes` or 11No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well snore:
repair under#21 remarks section or on the back of ibis form.
( If. , ; 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:1 ..I°��:I'�; i
1 I v/G� 24.SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: (ft:
For multiple wells list all depths ifd fferent(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: ' 11'96 (ft) 24a. For All Wells: Original foan!to Division of Water Resources (DWR),
If water level is above casing,use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Injection Wells:Copy to.DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
2.Well construction method:'Rotary
1
2.au ro 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
g tary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: ' .
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) a Method of test: BLOW
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Ib.
Form GW-1 ?North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6.6.201d