GW1-2023-01193_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: gI
1.Well Contractor Information: e, l�
Landon Phillips 14.WATER ZONES
Well Conlmclor Name FROM TO DFSCRIPT10N
3441 A 6 "' 17
' ft. rt. '.
NC Well Coulractor Certification Number
IS.OUTER CASING for multi-cased wells OR LINER if applicable)
NW Poole Well and Pump'Company rRont I To I DIA51E rEln TIHCKNNES/SS MATERIAL
Company Namo rb (J ft. 6In. r 1 a d u f i1 r«CI
16,INNER CASING OR TUBING Neollierniril closed-lot r
2.Well Construction Permit tt: FI ON To I DIAaI IX11 THICKNESS MATERIAL
l.tst Intl applicable well cormwctiolt perudLs Ae.UIC,County,State,Irarlance,etc.) ft. it. is
3,Well Use(chcelt well use): ft. ft. !n
Winter Supply Well: 17.SCREEN
1`11051 TO DIAMETER SLOT SI'LE T111CICNFSS MATERIAL
❑Agricultural ❑Municipal/Public rr. A. In.
❑Geothermal(1•icaling/Cooling Supply) Residential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri anion OWelIs>100,000GPD FROM TO MATERIAL ENIFLACEaIENT618TI10D&AMOUNT
Non-Water Supply Well: D rt. it. � il7�.o- i�C�2
❑Monitoring ❑Recovery ft. ft.
Injcclion Well:
'
❑Aquifer Recharge ❑Groundwater Remediation ft. ff.
❑At uifer Storage and Recovery OSalinil Barrier 19.SAND/GRAVEL PACK Ifri I Iicable
L g ry y FROM TO MATERIAL I EMPLACEMENTMET110D
❑Aquilcr'I•cst ❑Storinwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ff.
❑Geolliermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheds If necessary)
MOD! TO DESCIiu'•I•ION color,hardness soll/rack type, rain sit etc.
OGeolhennal(1-leating/Cooling Return) []Other(explain under#21 Remarks) O ft. ft. © r, o
4.Dale Well(s)Completed:!- I� Well 1D11 ft. ) ft' � t
Sa.Wpell )Location: /�/J / �` 1 tt. vsfl. et Un.� � -,} ,.:> e� pr �'?
-JA�..YLt� Y' `�-6kc-/ rt. ft. 1{ F. �,@ sC�7 iV =!z a.�.r`
ft. fr.
e)
Facility/Owner Nanic 'Facility ID9(irnfifilicablI A Al99
101 McAue 173 sPF('41 }lope Ale a7t7Ff,2- ft. ff. •
Physical Address,City,and Zip ft. ft. n �f; 'x;y r. tjnt< .
N f{.5 h 21.REMARKS a l!1 v T
County Parcel Idcnlifnealion No.(PIN)
51).Latitude
titude all(]lonlongitude
itudeiI cot)gr ees/minutes/seconds or decimal degrees:
22.Certifrcat '7
6:Is(arc)the wcll(s): QGPertunnenl or ❑Temporary Signature ofCcnificd Well Contractor Date
Uj,signhig this fora:,/hereby cart(f),that the ire//(i)inns(here)constructed in accordance iritlr
7.Is this it repair to an existing well: ❑Yev.:or L*JNo IJA NCAC 02C.0100 or ISA NCAC 02C.0700 Well Constnicdon Standards and ilia[a cop),
lt'this/s a repair,fill our known n•e//construction h fnrntatlon and explabi the nature ofthe afthis record has been pror8led to ilia well over.
repair under 1121 remarks section a•on the back ofthis fort:. 23.Site diagram or addllional well details:
i,i,, r ni
8.For Geoprobe/DPT or Closed-Loop Geotlicrinni Wells-having the same You may use the back of this page to provide additional well construction info
constriction,only I GW-1 is needed. Indicate�TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.5UB1111TTAL INSTRUCTIONS
L.
9.
F-or
well depth below land surface: ,3 ' (ftJ Submit this GW-1 within 30 days of well completion per the following:
For multiple yells list nN depths lfdWercut(exaurplc-3�U0'and 1 rr!UO').
24n. For All Wells: Original form to Division of Water Resources (DWit),
10.Static water level below top of casing: (fl Information Processing Unit,1GI7 MSC,Raleigh,l('iralcrlevelis above cashg,use"I." ) g g ,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su 1 and O en-Loa Geothermal Return Yells:Copy to the
(i.c,auger,rotary,cable,direct push clo) . courtly envuomnental call t department of the county w tare installed
FOR WATER SUPPLY WELLS ONLY:, I 24d.For Water Wells roducin over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpni) Method or test: BIoW Perron Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department ofLnvirorrnenlal Quality-Division of Water Resources Revised 6.6-2018