GW1-2023-01200_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Ilitenial Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name FROAf TO DESCRnsT10N
3441 A J 7 t. 70 rt. 1 -'1
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cored wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DrAAIETF.It T11ICKNESS MATERIAL
ft. ;,,,
Company Name i 5 � 1r. i , I C
16.INNER CASING OR TUBIN cothermnl closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell construction perittits(i.e.U1C,CaanO•,State;irarla) e,etc.J ft. ft. in.
1 3.Well Use(cheep well use): ft. ft. in.
Water Supply Well. 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS AIATERLIL
❑Agricultural ❑Municipal/Public ft. ft. in. ,
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. In.
ndustrial/Commercial ❑Residential Water Supply(shared) 18.CROU f
❑11TI aLion ❑Wells>100000GPD FROM TO MATERIAL, E51PLACENI ENT METHOD&MOUNT
Nou-water Supply Well: 6 ft. ft. ��f`u (]
❑Nloniloring ❑Recovery ft. ft.
injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation it. ft.
❑Aquifer Storage and Recovery ❑Salinit Barrier 19.SAND/GRAVEL PACK Ifa livable
Y FROM I TO MATERIAL, E51PLACENIENTNIETIIOD
❑Aquifer Test ❑StormwaterDrainage ft. it.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionnl sheets If necessary)
❑Geothenmal(1-Ieating/Coolisng Return) ❑Other(explain under#21 Remarks) raont To DESCRIPTION color,Iinrdness soll/rocktype,grain size etc.)
!7 fr. fL
4.Date Well(s)Completed:�- l `Z�hycll IDf/ -ft. 5 ft. �/
Sa.Well Location: ft. .ens ft.
ft.
Facility/Owner Natiic Facility IDA(ifapplicable) ` ft. ft.
.T �}/r C��/ C��S� ���lB/l �C. ft. ft. 7 23
Physical Addr1ess,City,
and Zip ft. ft.
County Parcel Identification No.(PIN) ` E' O �`f! G e,ifi,
5b.Latitude and longitude in degrees/minutes/s.econds or decimal degrees: <
(ifwell field,one fatllong is sufficient) 22.Cerlifrcat'
3G.o7 aa N -'7�i. 11 b33 W
6,Is(are)else well(s): ®Pernlarlent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this forni,l hereby certify that the irell(s)was 61'ere)constructed in accordance leidt
7.Is this a repair to in existing well: ❑Yes 'or LnNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 111ell Constritctloll Siauda•ds and that a copy
if lhis is a repair,fill out knouvr well construction h jori ation and explain the nature ofthe ofrlits record has been provided to the well onvier.
repair inider 821 remark;section oi•on the back of this forin.
23.Site diagram or additional well details:
S.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 i GW-I is)seeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attack additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "I9 S (ft.)
Far imdliple wells list all depths ifd�erent(example-3@200'and 2@100) Submit this GW-1 within 30 days of Drell completion per line following:
10.Static water level below top of casing: `� ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f•u•aier Jere/is above casing,use„+" ( ) Information Processing Unit,1617 MSC,Raleigh,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.auger cons,cabile,, method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to file
(i.e,auger,rotary,cab direct push etc.) county environmental ealt i department otWe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducin�100,000 GPD: Copy to DWR,CCPCUA
13a.Yield f BLOW Permit Program,16 MSC,Raleigh,NC 27699-161 I
(gpin) Method of test:
13b.Dishifectioit type: HTH Amount: 1 lb.
'Form GW-1 Nodli Carolina Deportment of Environmental Quality-Division of Water Resources Revised 6.6-2018
i