GW1-2023-01068_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(OW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14W. ATE&zONFS
FROM TO DESCREMON
Well Contractor Name
3441A (,s ft. 1•?O ft. �pl;JPrn
30 u. (9 55 ft D D'P/7,
NC Well Contractor Certification Number .-l5c`OUTERGASING.formulh casediwells OR`LINER if a Gcable
NW Poole Well and Pump Company FROM I TO DrAMETERi I THICKNESS AtATEtiTAI
Company Name
�( ft ' ft. in ' '��' �G_(V".CJ
�/ 1(i'INNER CASINCrORT UBING' "eothenii®t closed-loo
Z.Well Construction Permit#: Uf FROM To D1n1ETER TD1CtavEss MnTE[wL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in
3.Well Use(eheck.weli use): ft. ft. in.
s1.7IiSCRECN t:t� + ; '
Water Supply Well: FROM TO I DUMEMH, SLOTSIZE THICErMS M TERIAL
❑Agricultural ❑MunicipaVPublic ft ft. in.
❑Geothennal(Heating/Cooling Supply) Residential Water Supply(single) ft fr. ;n•,
❑Industrial/Commercial ❑Residential Water Supply(shared)
-y.1g.6go,T
131yrip,ation ❑Wells>100,000 GPD FROM I TO hfATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 13 ft. 0-te> ft L,p/ 09vv
❑Monitoring ❑Recovery ft. ft. v
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
14tSANDIGRAVEIs.PACK"ifa�lic6ble:'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO AUTERIAL I EMFLACEIVIENT 11fETHOD
❑Aquifer Test t I, ; ;i,l OStormwater Drainage ft. ft.
❑Experimental Technology oSubsidence Control ft. ft.
❑Geothennal(Closed Loop) []Tracer `20.'DRI1iliII�1G LOG:attach`nildiliou"ah heets'if.uecessa
FROM TO DESCRE TiON color,hardness sadfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 1121 Rcma±sj ft ft.
C� SC1
4.Date Well(s)Completed: —I Well ID# ft. C�1 ft
5a.Well Location: [� ( ft. 3p 5 ft. . ,u� ��� ly ^_ r .;"°z b
,Town of A a;
Falclility//O/wnerName 1 ` Facility IDff(if applicable) ft! ft JA
,9 I! CG�S��t sJz.�r y, K c' t t`fL:k� �L lvL c77j�� fa ft.
ft. ft. r wfr+ia�t^7I! .•s?t". t'.w•� unit
Physical Address,(ICity,and Zip I,
County Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minuies/seconds or decimal degrees:
(if well field,one lat/long is sufficient)• ! i!P,4 . i 22.Certifieati
I
N = P $33a W
6.Is(are)the well(s): ❑Permanent or 'bTemporary Signature of Certified Well Contractor j Date
By signing this form,I hereby cerio that;the wells)ivas(were)consmtcted in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 11rell Construction Standards and that a copy
If this is a repair,fill out known well construction infonnation and explain the nature of the of this record has been provided to the reel/oimer.
repair under#21 remarks section or on the back of ihts form.
i 23.Site diagram or additional well details:
8.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 Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled:t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths(f dtereni(exanyile-:3@200'and 2@I00')
n 24a. For All Wells: Original.form,,to Division of Water Resources (DWR),
10.Static water level below top of casing: «� (ft)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
i•. 6 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:' Rotary
('. . g rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
t e auger,ro 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,CCPCUA
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I J!j North Carolina Department of Environmental Quality-Division of Water Resourcesl I Revised 6-6-201a
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