GW1-2023-01047_Well Construction - GW1_20230125

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I
WELL CONSTRUCTION RtiCORll QW 1) PorInt elf al Use Only:
J.Well Contractor Inforulation.
Landon Phillips
14.1VA7'ER ZONES I
Well Contractor Neale FRohi TO I DFSCRIPTION I
3441 A rr. 70
I �
NC Well Conirnclor Ccnificalion Number fl• It.
15.OUTER CASING for multi-cased ivells OR LINER If n s slicnblc NW Poole Well and Pump Company FROM TO MATERIAL
TIIICICNESS MATERIAL
Company Name fl. rt. in!
n'/s(�- D r�r1 16.INNER CASING Olt TUBING eothernsni closed-loop)
2.Well Construction Permit H: I It li'�(/ "L �(,�/ FROM TO DNM11E'1'Elt 1'IIICI(NESS MATERIAL
Lift all applicable moll caun•ncrlon perarlts(i.e.UIL,Can ',Stale,Vorlanee,e(ti.) ft. C ff. in.
3,Well Use(checlt well use):
LOA
ply Well: 17.SCREEN
r, FROM 70 llIAM1IETER SLOT SIZE THICKNESS MATERIAL
❑lvlunicipal/Public ft. R. ill.
nal(1•Icating/Cooling Supply) ❑Rt sldenlial Water Supply(single)
ft. it, in.
/Comnnercial ❑Residential Water Supply(shared)
18.GROUT
❑WCIIs>100,000GPD FROM TO
Nun-lYatcr Supply tiYdl: IAT'RIAL EM1IPLA TENTM1IETnOD&AMOUNT
� '
❑M rt. fr.onitoring ❑Recovery rt. fI.
WOMP
Injection 1Vell: IF
❑Aquil'crRcchargo ❑GroundwalerRemediation n. n.
❑Aglitter Storage and Recovary ❑SaIIRIty Restrict 19.SAND/GRAVEL PACK if n licable
FItUM1t TO I MA1'EItL+L I EMPWCEMENTNIETHOD
❑Aquilbr•I'cst ❑Stonmvaterllrainage fl. ft.
❑L•xperimenlal Technology ',... IjSu6'siilence Control ft. ft.
❑Geolhcmnl(Closed Loop) r ❑'Tracer 20.DRILLING LOG nttach nddinonnl sheers If necosn
❑Geothermal(Idesiting/Cooling Reium) ❑Other(explain under 921 Remarks) Flto:n To ucsCRu"r1oN(color hardness soil/mck lyne, rein sim,etc,
t� ff.
4.Dale Well(s)Colnple(ed. —�/`2 Z Well IDH ft. ft.
Sa.1lrcll Location: ft. lip ff. �-
n
I ncilily/Owner Narirc psicilily Ill#(if applicable) ft. ft. tr a !f
`s J r_
lVO(`f1,Lr/1 si.r�s d�­���� y'4.�rt�Physical Address,Cay,a ndZip 1 I":i . 11,:1: ft. ft.
r(a r di 2I.REMARICSCounly
Parcel Identification No.(PIN) 01,"jQIUt�U
5b.Latitude sued longitude in degrees/nlhnllcs/secouds or decinsal degrees: v
(il'wclll feeld,one
IIn�nt/long is sliff�ieiicc}nl)1 Q 2 22.CCfIiGCaC
6:Is(gre)tine well(s): ®I'erulallent . or .I7Tchipornry Signalure'ofCenirwd well Connracror Dnic
Byslgnbrg thisforal,Mar by certif•dot the well(T)was(mere)constricted in accordance with
7.Is tills a repair toast existing @'ell: ❑Y61•,;or IJNO ISA NCAC 02C.0100 or 15A NCAC 02C.0200 II'e//Coasuvcaon Standards and that a copy
/)'this it n r epnlr,frll c+ur known urll carsn actiar lnfor I�lloit and explain the naan•e of(lte (10111r record hnr been pro'Ided to the well urcncr.
repair under 1121 rentar•kr section or oil(!se back of thIs fa•nl. lt.
23.Site dingram or additional tivell delaiIs:
8.Fo•Gcoprobc/DPT or Closed-Loop Geothc'r'nisil Wells having the same You may use the back of Ibis page to provide additional well construction info
construction,oill I GW-I is needed. Indicate TOTAL NUMBER ofwells (add'Sec Ovee ill,Remarks Box).You may'also attach additional pages ifllecessary.
y 1 h,,,,l,
drilled: '
I fl:tw� 24.SUBMITTAL INSTRUCTIONS
9-Total well depth below hand surface: J
Fqr authlpfe srcllr list nN depths jdOerrn((ecample-3 a 200'and 1Q1U0 j (f t) Submit tills GW-1 within 30 days of well completion per the following:
10.Static water level below lop oCcasing: 1 (tl) 24n. For All Wells: Original form to Division of Water Resources (DWR),'
//ltnlcr(oral is abure cashig,rice^•i 6' ;I I.I lufonnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (iu.) 24b.For Injection Wells:Copy to DWI?,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-16j6
12.Well construcHdri mctliod: I
(i.e.imgcr,roinry,cable,direct push,cic.) I I 24c.For Water Sunly and O en-L op Geblb rnml Return Wells:Copy to file
county environmental health departmentof the county,where installed
FOR WA'I'1'sR SUPPLY'vYCLLS ONLY:; ,I('�,1j'!a�i
24d.For Water Wells producing:over 100 000 G T. Copy to DWR,CCPCUA
13n.Yield sort "' BIOW lrennrt Program, I611 MSC,Kalcigh,NC 27G99-IGI 1
(glint) a Method of
HTH 1 lb.
13b.Disinfection type: Amount:
Form C\V-I North Carolina Deparhnenl ofEnviromnentol Qunlily-Division of Wnler Resources i Revised 6.6-2018
i r 'J4,4:1 !,