GW1-2023-01065_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only; ..
1.Well Contractor Information:
Landon Phillips 14iiWATERzONE9
FROM TO DESCRIPTION
Well Contractor Name i
3441 A � ft.
ft, ft
NC Well.Contractor Certification Number +15 OU.TERCASING.feririultt cased wells:OR'LINER if e "licatile
NW Poole Well and Pump Company FROM TO DIAMETER ' THICIss MATERIAL
fL
Company Name `
'16:�INNER CASING.ORaUBWG eoihcrmel clased,tbii
2.Well Construction Permit#: '3oN FROM TO DIAMEM I I THICKNESS h MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. la
3.Well Use(check well use): ft ft. in. _ -
�i7SCREEN
Water Supply Well: FROM I TO DIAMETER 1. SLOTSrZE THICKNESS MA•rr,RIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18GROUT - 1
❑Irri ation ❑Wells>100,000 GPD FROM TO 11UTERIAL EMPLACEMENT METHOD lS AMOUNT
Non-Water Supply Well: 0it Z p fry e r --J
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation i
19i'SAND/GRAVEL PA6+&'if a llCalile ��
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test h• OStomtwater Drainage fr. ft'' "
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 12o:�DRIL•L-INO!LOG attacliaddittouelsheetsifuccessa
111, I FROM TO DESCRIPTION color hardness soii/rock type,grain size,etc. I
❑Geothermal(Heating/Cooling Return) •_ ❑Other(explain under#21 Remarks) ft. Z ft. ,
Tv '
4..Date Well(s)Completed: 1'10-43 well ID# .Z fa G tt,` !•
5a.Well Locatiion:iJ1 /I 0 ft. `14. trCiAi�{� C 4 5 i
G�U �tJ6tt/l ft. ft:: I 9 V C —�
Facility/ nerName / /� Facility ID##(((ifapplicablle) ft. ft. , 1
f�S-6s-�ZZt?r'I �mv� G111 �l� l�r�vrceArl ft ft:
Physical Address,City,and Zip ft fk tr Mi mz' -,n pr i C3L`ong UM,
n-s�i� Used hardened steel drive shoe. <
County i.r Parcel Identification No.(PIN) --i
5b.Latitude and longitude in degrees/minute`s/seconds or decimal degrees: --
f well field,one latllon is'sufficient) rY'll,i t
(i g' ) �• � 22.Certificati
6.Is(are)the well(.$): ❑Permanent or ❑Temporary Signature of Certified Well Contractor j' Date
By signing this farm,I hereby certify thar the+vell(s)was(were)constructed in accordance faith
7.Is this a repair t o an existing well: �l'es`tir I�INo
' 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Nell Construction Standards and that a ccDv
If this is a repair,fill out known well construction itlfortmation and explain the nature of the of this record has been provided to the well owier.
repair under#21 renidrks section or an the back ojilr!s;jorin.7 ,, '
i.• 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts 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:+
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (it)
For multiple wells lisi'all depths jdi(ferent(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: (F... (Z G (ft) 24a. For All Wells: Original form to Division of Water Resources (I)Arp.i,
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:-6 r (in.) 24b.For Injection Wells:Copy to D.WR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC.27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop,Geothermal Return Wells:Copy to tha
(i.e.auger,rotary,cable,direct push,etc.) ,;/i1j 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,CCPCUs
13a.Yield(gpm); 3 6 Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amouut:'1 lb. f
Form GW-1 J..,1;, i'North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-201 S