GW1-2023-01052_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips la.WATER2ANEs
Well Contractor Name FROM. TO I DESCRH'TION
3441 A v a. q ft.
n. IL
NC Well Contractor Certification Number 15i OUTER CASING far mtilti-cased wells OR LINER if applicable)
NW Poole Well and Pump,Cornpany FROar TO DIAMETER THI rwESSI MATERIAL
Company Name
c 16.INNER CA NG OR.TUBING 'eothermalclosed-lnonl
2.Well Construction Permit 9: W5 �,NC+c) gQ1D_E7 FROM TO DIAMETER I TIHCKNESS I aATERIAL` ,
List all applicable well constructionpennits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ; ft. ft. In.
Water Supply Well:' '17:SCREEN.
FRO51 TO DLAMETER J.SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural OMunicipaUPublic ft. H. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
bidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL' Et11 CEhIE IETHOD&AMOUNT
Nou-Water Supply Well: ft. ft. , i m
❑Monitoring ❑Recovery ft. ft:
Injection Well: I
ft. ft. I
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a Hcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• n• i
❑Experimental Technology '❑Subsidence Control iL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
FROM TO DESCRIPTION color,hardness,soillrack e, rain sir etc.)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) tt. ft.
62
4.Date Well(s)Completed: TWell ID# it. tt.
Sri.WollLocntion: It. O ft.
5��G f�foPcr,i rr De uQ(a//hc�s,• ft. ft.
Facility/Owner Nr;i c "" 'Pacility:ID#(if applicable) fit fit.
c•'°' y,M,,,,
or+,l F"115 , - r✓�,�w..•� ft. ft.
N t, rba f
Physical Address,Cit}•,and Zip !• ft. ft.
it 97
21.RE1 upm
� t
%96 Parcel Identification No.(PIN) 1�+��++•-�.'•.�� �� _ ,-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lon sufficient i
e/ I e is ) 1 22.Certifica !,
6.Is(are)the well(s): ®Permanent or „OTemporary'.' Signature of Certified Well Contractor Date
By signing this forni,I hereby cert fy that the ivell(s)is-as(here)constructed in accordance irith
7.Is this a repair to an existing well: ❑Yes'!:"or.' ©No ISA NCAC 02C.0100 or 15A NCAC 02C.0200!Yell Construction Standards and that a copy
If filds is a repair,fill out known ire//construction h jor'mailon and explain the nature of the ofthis record has beenprovided to the ivell owner.
repair under#21 remiarks section or on the back ofthis form.
u1 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothci•mhl.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,TOTALiNUMBER of wells (add'See Oven'in Remarks Box).You may also attach additional pages if necessary.
drilled: t V.
24.SUBMITTAL INSTRUCTIONS':
9.Total well depth below land surface: r' J d ft.
For multiple irells list all depths ifdierent(example-3@200'and2@100D ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z fit 24a. For All Wells: Original form to Division of Water Resources (DWR),
lf,rarerlerel is above,cas/ng,use ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Z4b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i
(i.e,auger,rota 24c.For Water Supply and Open-Loop Geothermal Return�YeIls:Copy to the
rotary"cayie,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: ;Ili'I!;°
„k0l.,:%„I, 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) V Method of test:
BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
HTH 1 lb.
13b.Disinfection type: Amount:
Form GW-I lNorthlCarolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
' I