GW1-2023-01069_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES ! !
Well Contractor Name FROM TO DESCRH'ITONI
3441A ft. 1 '
rt.NC Well Contractor Certification Number ft.
15.OU.TER CASING for multi:-cased wells OR LINER if applicable)
NW Poole Well and Pump Company OM TO DLUt MR I I I TIUCIavEss I MATERIAL
Compapy Name ft ft. in. . I-c 6 G�ilrLti
Qn�G/U 6.'INNER CASIN OR TUBING eothermal cured-loo
2.Well Construction Permit#: _/l/ J a FROM TO DWIETER 1 THICKNESS MATERIAL
List all applicable trell construction permits(ram e,UIC,County,State,Varlance,etc.) ft ft. is
3.Well Use(check well use).. R. ft. tn.
Water Supply Well: .17.'SCREEN.
❑A ricultural FROM TO DIAhfETER SLOTSIZE THICKNESS arATERIAr.
g ❑Municipal/Public IL ft. in.
[]Geothermal(Heating/Cooling Supply) tesidential Water Supply(single)
ft. ft. in.
❑bidustrial/Commercial ❑Residential Water Supply(shared)
"18..GROUT
❑Irri ation ❑Wells>100,000 GPD "SANDIGRAVEL
htATERtAt EMPLACEafENT r1EIHOD&AMOUNT
Non-Water Supply Well:❑Monitoring ❑RecoveryInjection Well:❑Aquifer Recharge ❑Groundwater Remediation❑Aquifer Storage andRecove ifa licable
Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT AMMOD
❑Aquifer Test ,t 14�! ',❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fr. ft.I..
❑Geolhennal(Closed Loop) ❑Tracer :,2%DRILLING.LOG attach additional sheets if necessary)
t'f FROM TO DESCRIPTION color,1—dncss,soil/rock q rain six etc.
❑Geothermal(Heating/Cooling Return . ..❑Other,(ex lain under Remarks)
1 0 ft. fa rC
4.Date Wells)Completed:EZ 1- Well ID# ft. fc
�5a/.1WSe(l-1 Lnocat�ioPn�:� `7
ft. 1 r,
Facility/OwncrNmncr� PacilityID#(if applicable) C) ft. ft. JAN 2 5`2023
�Cfl�i ft. fL
Physical Address,City,'ntid Zip 1., •!' ft. ft
'roen ll 21:RMAMAMCS
Cowtiy 4 Parcel Identification No.(PIN) Used hardened'steel drive shoe.
5b.Latitude and longitude in degrees/minutes%seconds or decimal degrees:
(iftvell field,one ladlong is sufficient) 1 ;I �9�,4a
22.Certificati
:)J. laq(DUCj�I N _'"�IR`.?i�tlrl23 W
6.ls(nre)the well(s) '0Permanent or ❑Temporary Signature ofCcrtificd Well Contractor Date
By Signing this forni,/hereby cert!fy that them-ell(s)was(irere)constructed in accordance frith
7.Is this a repair to•an existing well: ❑Yes `or '11No 15A NCAC 02C.0100 or 15A NCAC 02C.0100 lfrell Construction Standards and drat a cony
If this•is a repair,fill an known+rell construction Irrfornratiat and explain the mature oj0ie of this record has beery provided to the well oirner.
repair under 1121 remarks section or on the back of dNs forirr.
;'r;nll Ir, 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geotheemali7Wdls having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTALINUMBER 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: -` n Q
!-or 11111h /e wells list ail depths tfdlfferetu(example-.3 0,o..",rid 2®100') Submit this GW-1 within 30 days of well completion per the following:
I
10.Static water level below top"i of casilig: } (fL) 24a. For All Wells: Original form to bivision of Water Resources (DWR),
If Water level is above casing,use^+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL Borehole diameter: 6 '(in.) 24b.For Injection Wells:Copy to DWRI,Underground Injection Control(IUC)
a Rota Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ry hl li
(i.e.augor,rotary,cubic,direct push,etc.) 24c.For Writer Supply and Open-Loop Geothermal Return Wells-Copy to the
•i .. I,p 1 county environmental health department of the county where installed
i
FOR WATER SUPPLY,WELLS ONLY: "'
24d.For Water Wells producing over 100,600 GPD•Copy to DWR,CCPCUA
(gP ) Method of test:
13a.Yield m BLOW Permit Program,1611 MSC,Raleigh,NC I7699-1611
13b.Disinfection type: HTH Amount:
Form GW-1 ,
,i•NoSth+Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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