GW1-2023-01197_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD (GIN I) For Intemal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441A •o',
rt. rc. i
NC Well Contmctor Certification Number
15.OUTER CASING for multi-cased +ells OR LINER ifu licn6le
NW Poole Well and Pump Company FROM To DrAn1ETER TnICKNESs r DATERIAL
Company Name f-t ft. I'nj ft. 1 to in.' s 02� C?�
16.INNER CASING OR TUBING eorhermal closed-loop) 1
2.Well Construction Permit#:�z Z— 00O-5I O hROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perntils(f.e.UIC County,State,Parlance,etc.) ft. ft. in
3.Well Use(check well use): ft, ft,
Water Supply Well: 17:SCREEN.
❑A rieultural FROM TO DIAMETER SLOT SIZE TIQCKNFSS MATERIAL
g ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) / sidenti.1 Water Supply](singl( ft. It.❑Industrial/Commercial ❑Residential Water Supply 18..GROUT
❑Irri ation ❑Wll > 00,000 GPDFROM TO MATERIAL EMPLACEMENT MErHOD&AMOUNT
Non-Water Supply Well: �l ft. ft —
❑Moniloring ❑Recovery V tr• ( ff• 6,oh
Injection Well:
❑Aquife'rRecharge ❑GroundwaterRemediation R• ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENT AIETIIOD
❑Aquifer Test ❑5tormwaterDrainage It. fr.
❑Experimental Technology ❑Subsidence Control "DRILLING
❑Geothermal(Closed Loop) ❑Tracer h additional sheets if necessar❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) DESCRIPTION cot r tinrdness,aon/rocky re, ainsize,etc.4.Date Well(s)Completed: —Z ZWell ID#5a.Well Location: U t. . ft• �.� ^ i
"11 r 0 'G 1� . �;�
Facility/Owner Name Facility 1D#(ifopplicaable) ft. ft. , 23
EE�l7 f�PPii..�,'2 1 �rr1C /U1�C� rc. rt i3.1 r�Urrl
Physical Address,City,and Zip " 5:3� r
21.REMARKS
Cowry Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one ladlong is sufficient)
r�6 d po may' �� 22.Certiticati
'J Ud �r N �0 W
G.Is(arc)the wcll(s): ❑Permanent or ❑Tem'porary Signature ofCcrtified Well Contractor Date
A)'signing this form,/hereby certify that tha.well(s)was(here)constructed in accordance u•idt
7.Is this a repair to an existing well: ❑Yes `or' 8No 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Ifrell Consiriction Standards and/1:at a cony
!fills Is a repair,fill out known ire/i construction h formation and explain the nature of tlta of this record hat been provided io ilia well owner.
repair tinder 1121 remarks section or an the back of dds fort''1"
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'Sce Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled'1 ; .
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 71 I S J (ft)l`o Submit this GW-1 within 30 days of well completion per the following:
r nudilnle u•e//s list nU depdrs if d�ereni'(esomple-3 rt 100'and 1Q100')
10.Static water level below top of.casing: zi c? (fL) 24a. For All Wells: Original font to Division of Water Resources (DWR),
Ifn•ater level is above casing,use"i•" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 '(in•) 24b.For Injection Wells: Copy to DWR, Underground Injeclion'Control(IUC)
12.Well construction
Rota Program,1636 MSC,Raleigh,NC 27699-1 63 6
method: ry
(i.e.auger,rotary,cable,direct push,etc.) 24e.For Water Supply,and Open-Loop Geothermal Return Wells:Copy to die
county environmental health department of the county where installed
`.ItOR 1VATER SUPPLY WELLS ONLY: •' "'I
24d,For Water Well producing over 1110 000 GP D Copy to DWR,CCPCU/!
13a.Yield to BLOW Permit Program,.1611 MSC,Raleigh,NC 27699-1611
(I;P ) Method of test:
13b.Disitifeclion type: HTH Amount:
1 Ib.
Porn GW-I North Carolina Department ofEnvironmcntal Quality-Division of Water Resources Revised 6.6-2018
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