GW1-2023-01185_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: %l �1�
Landon Phillips 14.WATER ZONES
_ Well Conimclor Mine : FROM TO I DESCRIPTION
3441 A rt. rr.
Sc.
ft. a.
NC Well Contractor Certification Nmnber 15.OUTER CASING far multi-cased wells OR L[NER if a licable
NW Poole Well and.Pump Company FRol TO DIAM1fETIiR TIIICKNESS M1IATERIAL
ft.Compmry Name 6a ft. In. LtVl, lgy l
w I 7 16.INNER CASING OR TUBING eothermnl closed-loop)
O ?2.Well Construction Permit H: ,D FROM TO DIAMETER TInCKNESS MATERIAL
List all applicable well contruction perutlts 0.e.UIC,Conroy,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL '
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geotlnerinal(Heating/Cooling Supply) }�liesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial !❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AM1tOUNT
Non-Water Supply Well: O It. ao ft. o V
❑Monitoring ❑Recovery ft. rt.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
I ❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicribleFRont I TO I MATERIAL EairLACEMENTM1IETROD
❑Aquifcr•rest ❑StonnwaterDrainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional streets irnecessa
FROM I TO DESCRD''fION color Itanlness soil/rock type, min sin etc.
❑Geothennnl(1-leatirig/Cooling Return) ❑Other(explain'under 421 Remarks)
4.Dale Well(s)Completed: - �.2` Well Illl1 v� ft. ft. �^ 1�
r i
5a.11'cll Localioin•
ft- ft. G11�-
I+Old ) I&('s e. rt. -
1 ;,.
facility/Owner Nontc I Facility Ill#(ifopplicable) ft. ft.
Physical Addiess,'City,and Zip _ I i',!' �� ft. ft. J
I T. 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude ant!longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long issufficient) 1'1'"1,1'* 22.CCrtifiCat'
6:Is(arc)the well(s): ®Permanent or: .btempornry Signalure orCenifred Well Contractor Dale
By signhig this form,I hereby cert j,that the ivell(r)was(here)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes":or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 11'ell Cointniction Standards and that a copy
IJ'thts Is a repair,fill our known well cottstritciioit iiifoiixuiio'i and explain lite nature ofthe ajthis record has beenproi1ded to the well olrner.
repair trader#21 remarks section or on the back ofthis forth.
n 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(his page to provide additional well construction info
construction,only I GW-1 is needed. hldicate,TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well dep(h.below land surface: (ft.
For undliple irells list all depths LfdWeretrt(example-3 a 200'and 2@100) ) Submit this GW-1 within 30 days Ohve11 completion per the following:
10,Static water level below top of casing: '', ! :I G(J. (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
i/lrater level is above cas•in g,Ilse"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i'�. it
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.1\tell construction method: 24c.For Water Su 1 and O en-Loo Geotkermal Return Wells:Copy to the
(i.c.auger,rotary,cable,direct push,etc.) ';; 1, county environmental health department o the county where installed
FOR WATER,SUPPLX WELLS ONLY ;i,' , 24d.For Water Wells roducin .Over lU0 000 GPO: Copy to DWR CCPCUA
P !: ' Blow Permit Program,1611 MSC,Ralerg n,NC 27699-1611
13a.Yield(gpin) Method of test:
13b.Disinfection,type: HTH Am6unt: .1 lb.
Forni GW-1 North Carolina Deportment of Envirorunentat Quality-Division orWater Resources Revised 6.6.2018