GW1-2023-01051_Well Construction - GW1_20230125

I .
WELL CONSTRUCTION RECORD(GW=1) For Internal Use Only: I.
1.Well Contractor Information: „ I
Landon Phillips
!' .14:WATER ZONES i
Well Contractor Name FR0111 TO DESCRIPTION
3441A t6S I4 170 ft. b 1p,
ft. ft.
NC Well Contractor Certification Number
.15:OUTER CASING for multi-cased well's OR LINER if a licable
NW Poole Well and Pump Company FROar TO DIAMETER THICKNESS nIATERIAL
Company Name l It. 1, It. 1 in. d (�f '
V
// 16.INNER CASING ORTUBING eothermat closed-loo
2.Well Construction Permit M 36b3 /'� FROM To DIAMETER THIC!—KNES I AIATERtAL
List all applicable well constnrctionperarlrs(i.e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): R. ft. in.
FYater Supply Well: 17:SCREEN
❑A [iCUlWral FROM TO DIAMETER l SLOT SIZE THICKNESS mATERLIL
g ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tr. tt. in
❑industrial/Commercial ❑R6iidential Water Supply(shared) :18:GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO 51ATERIAL E111PLACEI%IENT METHOD&AnIOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Ltjection Well: - •
i'❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19:SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEnIENT hIETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. ;
❑Experimental Technology 'fl7Sulisiilencd Control ft. ft.
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLWG LOG attach additional sheets if necessa
❑Geothermal(Hdating/Cooling Return) ❑Other(explain under#21 Remarks) FROM .'TO DESCRIPTION color,hardness sollfrock type.grain size,etc.)
ft. rr. O �fl C
4.Date Well(s)Completed: Well ID# ft. ft. ;C � f/
S.
5a.Well Location: it. ft*
C�� CUSf(JM I �� ft. ft.
Facility/Owoer Name Facility lD#(if applicable) ft. ft.
1003 3 cb w r`l�� �l�c� MVg'i/ R .-a7sy6 ft. ft. r' -� ,
?'�-_- a�
Physical Address,City,and Zip' i' ft. ft. d Ef s;_,
id
1+ 21;REMARI{S 2
County
� ,.,Parcel Identification No.(PIN) r
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
� 5�c�� 22.Certlfcat
J ,I
e V�P N �� V W 2
6.1s(are)the well(s): ®Permanent or- OTdmporary Signature of Certified Well Contractor Dat
By signing this form,I hereby certto that die ivell(s)was(were)constructed fit accordance with
7.Is this a repair to an existing well: ❑Yes.!or ©No 15A NCAC 02C.0100.or 15A NCAC 02C;0200 Well Construction Standards and that a copy
lf'this is a repair,Jill out known well construction Drfor`rnatlon mid explain the nature ofthe of this record has been provided to the well,owner.
repair under#21!renrarks section or on the back of this form.,
! 23.Site diagram or additional well details:
3.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'See Over'in Remarks Box).You'may also attach additional pages if necessary.
drilled: "
a !1„,! •((��,�, 24.-SUBMITTAL INSTRUCTIONS
9.Total well depth.below land Is rrV� • g, i
Fa•undriple sells fist all depths ifdgerent(exatrrple 3@200'and 2Q100) ( ) Submit this GW-1 within 30 days of well completion per the following:
1fi
10.Static water level below top of casing: b (ft. 24a. For All Wells: Original form) to Division of Water Resources (DWR),
If,rarer•level is above casing,use 1.,^ y !;I @ ) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
1.1.Borehole diameter: r (io,) 24b.For•Iniection Wells:Copy to I9WR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well cous(t4ction method: j
(i.e.au g er,rotary,cable,direct push,etc.) 24c.For Water Supply and Oven-Loan Geothermal Return Wells•Copy to the
i F county environmental health department,of the county where installed
FOR WATER SUPPLY WELLS ONLY; 24d.For Water Wells producing over Ill76"0 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) I V Method of test: BIOW Permit Program,1611 MSC,Raleigh,iNC 299-1611
.1 lb.
13b.Disinfection'type:` HTH A�tiunt: 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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