GW1-2023-01196_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD (GW 11 For Internal Use Only:
i.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name MOUTERCA�SING
DFSCRIri'ION
3441A ft. S i A
NC Well Contractor Certification Number
NW Poole Well and Pump Company multi-cased wells OR LINER ifn licnblcDIAI1tETER TInCKNESS AfATERL\LCompany Namc )J //
2.-Well Construction Permit#: �a a- D bo�iG 16•INNER CASING OR TUDING eothermal clo3ed-loo i
FROM TO DIMIETER THICKNESS MATERIAL
List all applicable Well construction penis(i.e.UiC,County,State,V latrce,ete.J ft. ft. in
3.Well Use(cbecl(well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
❑Agricultural FROM DIAMETER ,SLOTSIZE TIIICKNFSS MATERIAL
❑Municipal/1 ublic U fL ; G
❑Geothermal(Healing/Cooling Supply) 1 Residential Water Supply(single)I v 2Ile
❑Industrial/Commercial ft•
❑Residential Water Supply(slfared)
❑Irri ation 18.GROUT
❑Wells>]O0,000 GPD FROM TO MATERIAL EMPLACEMENT hiErHOD&A6IOUNT
Non-Water Supply Well: Ill
❑Mon g itorin ft. O It- O/C' , v
r
Injection Well: ❑Recovery
ft. ft, r
❑AquiferRecharge ❑GroundwaterRemediation ft. ft.
❑Aquifer Storage and Recove 19.SAND/GRAVEL PACK if livable
ry ❑SallnityBarrier FROM1t TO MATERIAL EAIPLACENENTIIIETIIOD
❑AquiferTest ❑StormivaterDrainage 6 lt. R.
❑Cxperimental Technology OL)
❑Subsidence Control
,
ft. It.
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG aflach ndditionni sheets if necessa
❑Geothermal(Fleatitlg/Cooling Return). ❑Other(explain under#21 Remarks) FRonI To DESCRIrrlot, c/o�,."kardacas, .H1rock type, rain sire,crc.
4.Date Well(s)Completed: —'20-2Z Well1D# ft. /1 ft �k Y —
5a.Well Location: fL nC
LIP
Facility/Owner Namc A Facility ID#(if applicable) ft. ft. JA N 2 7
LI�`��n--i-f7 n, �,n.rJ I t1 I fC d br< Y X/L o?7 SS ft. ft. ^
Physical Address,City,aiidZip ft. ft. Ur'.�
- /v`46 h
21,REMARKS
County Parcel Identification No.(PM) Used hardened:steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell ficld,one lal/loug is suffreicil()
�IC l----N 22.Ccriificau
35. ''?�3• l�io•I'�LD W
-
6.Is(nre)the wells: ❑Permanent O or ❑Temporary Signature ofCcnificd Well Contractor Dale
BY signing dds four,ihereby certify that than ells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes oi' 6No 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a cony
!(this is a repair,fill out knorn well construction(formation aid explain the nature ofthe of this record has beer provided to the well ee rn :repair under#21 remarks sectloa or on the back of this jortu.. ..•
a 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal•Weps 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:+ H: ;j:
J 24.SUBMITTAL INSTRUCTIONS
9.11otal well depth below land surface: l,b s (ft.)pornilthiple trellslist alldepthstfdiperent(example-9(q200,'aud2@100') Submit this GW-I within 30 days orwell completion per the following:
10.Static water level below top of_casing: 2(� (f1•) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If o•aicr/cycl is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I1.Borehole diameter: 6 '(in.) 24b.For Infection Wells:Cop
y py to DWR Underground Injection Control
(IUC)
12.Well construction m et hod: Rotary Rota Program,1636 MSC,Raleigh,NC 27699-1636
it ,..;':,
(i.e.auger,rotary,cable,direct push,etc.) 24e.For Water Suvuly and ODen-Loop Geothermal Return Wells:Copy to the
FOR WATER SUPPLY
county environmental health department of the county where installed
WELLS ONLY:'
C 24d.For Water Wells producing over inn 000 GPD•Copy to DWR,CCPCUn
13a.Yield(gpin) �J Method of test: BLOW Permit Program, l61 I MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Qmou'nt: 11 lb.
Porn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6.6-201C
1