GW1-2023-01046_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use OBIy:
•1.Well Contrnctor Information:
Landon Phillips ia.WATER ZONE
S
\SrcllContmciorNmna FROM TO UESCmPTION
3441 A 3 a.5 5SO'!�
ft. ft. Z �
NC Well Coulrnclor Ccnifirntion Number 6 6.5 Qp
�,M�
1 IT OUTER CASING for muhl-cnsed wells 'OR LINER If n i dirnblc
NW Poole Well and Pump Company FRDnI UTADI F,TER ( TIIICICNESS MATERIAL
a. '7 n. in. v fvy„�I
Company Nanc p 1 rs
16.INNER CASING OR TUBING eothermnl closed-loo r
2.Well Construction Permit ff: FROM TO DIAAIUI'Elt t I 7'111CKNESS MATERIAL
I.I..rr all applicable well corrst•uctiort permits Q.e.UIC,Cmotl);State,Variance,etc) ff. ff.
J.Well Use(chcCit well use): ft, ft. 1n.
Water Supply Well: 17.SCREEN
FROa1 TO UTAnIETEB SLOTSIZE TIRCKNESS MATERIAL '
❑Agricultural ❑Municipal/Public ft.
❑Gcolherinal(1•icaling/Cooling Supply) Residential Water Supply(single)
❑Industrial/Commercial ,❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Welis>100,000GPD MGM TO MATERIAL EMPLACEMENT ME771OD&AMOUNT
Noll-WntcrSupplyflrcll: ft. n
❑Monitoring . ❑Recovery ft. rt.
Injection Well:
❑Aquila Recharge ❑Groundwater Remedinlion
❑Aquifer Storage and Recovery ❑Salinll Barrier 19.SAND/GRAVEL PACK if n licable
y FHOM TO I n1ATEMAL EMPLACE51ENTMET110D
❑Aquil'cr'I'csl ❑Slonnwaler Drainage ff. fL
❑Experimental Technology OSubsidence Control ft. ff.
❑Geothermal(Closed Loop) i ❑'tracer 20.DIULLING LOG 01facia ndditional sheets irnecessa
❑Geothennal(1•leating/CoolingRetum) OOther(explainunder#21 Remarks) MOM To yescim-rioN colorharmwss m soroeht e, rnin size,etc.
8 ff. 7 ft. S.
Dale Well(s)Conlpleled: -aS^ - 2 Well iD11 It. 3 ft- C:f-;
5a.Well Location: ft. 70 ri.
PrdL� p Detu ��rr rti
Faciiily/Owner Name !' Facility IDN(if applicable) ft. ft. ­i,It® _t _i V
(9 F . Bra ' r,�, rfl ti 7023
Physical AMcss,City,and Zip ft. ft.
21.REMARKS
tG t i �_,
Count), CsL"MI D
, Parcel Identification No.(PIN)
OG
i
5b.Latitude and Iougihide in tlegi'ces/minutes/seconds or decimal degrees:
(il'wcll field,one ladlong is suiticimti) 22.Cel'tifCRC
6:Is(Ilre)the n'ell(s): ®Isern)nnent or OTemliorni3, SignatureorCertified Well Contractor Dnlc
Uy signing thisjam,thereby cert6r),that the well(r)was(were)constructed to accordance with
7.is tilis:l repair to fill existing well: ❑Yes o or, nNo iSA NCAC 02C.0100 or ISA NCAC 01C.0j00 IFe/l Construction Standards and thar a copy
iJ'INT hr a repair,fill out known well cons-t uction Lt/or•iriatinn and esplaht tlic mata•e ojtho t(this record has been pro4ded to ilia well owucr.
repair under i111 remarks suction or oil ilia back ojth/s joint.
r' �•� 23,Site diagram or additional well details:
3.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide additional well construction info
c011stuC6011,Only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBA1I17AL INSTRUCTIONS
OS9-Total 5vcll depth below land surface:— 7 (ft.)
i'nrmm/tple n•eIlr list nadepths lfd69erent(example.3 aV1 00'and 1Q100') Submit this GW-115'ilhin 30 days of 5)'Cll Cotttpiclioth per lift following:
a610.Static water level below lop of casing: (Cl) 24a. For All Yells: Original form to Division of Water Resources (DWR),
I/lraicr hwa/is nbure casing.use"•i" " '' information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Iloreliole dignieler' (ilt,) 24b.For L)icclion Wells:Copy to DWR,Underground Injection Control(!UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:,'Rotary 1 i
(i.e.nuger,rotary,cattle,direct push;'cic.) 2Qe.For Water Su i and O en-Loo Geolhernwl Return Wells:Copy to the
county environmental heath t department o the county where installed
1,011 WATER SUPPLY WELLS ONLY:
24d.For Water Wells rotlucin g over 100.000
Glsll:Copy(o DWR,CCPCUA
131.Yield s)in BIOW Pennit Program,161 MSC,Raleigh,iC 27699-161 I
(61 ) Method of test: i
136.DisinCeclion type: HTH Amount: 1 lb.
Form GW-I Nonh Cmolinn Ucparinicwl ors Quality-Divisiou of Writer Resources ( Reviscd 6.6-2018
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