GW1-2023-01206_Well Construction - GW1_20230127

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WELL CONSTRUCTION RECORll(GW 1
' � Pot Internal Use ODIy:
I.Well Contractor Information:
Landon Phillips
14.WATER ZONES
1t+ell Conlrnclor Nano FROM TO DFSCRIPTION
3441 A D rt. a
NC Well Coutraclilr Certification Number rf• ft.
15.OUTER CASING for multi-cased wells OR LFNER ff al
licable
NW Poole Well and Pump Company ]FROMTO UInnIF-rER TInCICNESS MATERIAL
Company Nnuic ft. �y fr. in.
2.Well Construction Permit q: t-` W`—t��p2q� 7z 2 16.1NNER CASING OR TUBING eothrrrunl closed-loo, '
FltOpl TO DIAMETER
MATERIAL
Lis!all applicable well concn•uctial per"11ty(i.c.WC Cnmlty,Stare,Variance,e/aJ ft. ft.
3.Well Use(cliecli well use): fr. ft.
Water Supply Well: 17.SCREEN
❑Agricuhural rmonl TO DIAMETER SLOT SIZE TFIICIQVFSS MATERIAL
❑Municipal/Public ft. ft. i,i
❑Geothermal(l-leating/Cooling Supply) Residential Water Supply(single)
❑Industrial/Commercial � � ft• rt. in.
❑Residential Water Supply(shared)
❑Irri ation 19.GROUT
❑WeIIS>100,000GPD ITHOni TO atATE1t1AL EMPLACEMENTAICTROD&AMOUNT Doom grinter Supply Well: 6 ft. 02 r� rt.
❑Monitoring ❑Recove Q�
Injection Well: ry fr. O.
❑Aquilcr Recharge ❑Groundwater Remediation rt. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier NDIULLING
VEL PACK if n licahlc
TO MAl'Ero,"' EpTPLACENENTMETtIOD
❑Aquifbi-Test ❑StornwaterDrainage❑L•xperimental Technology ❑Subsidence Control❑Geolherinal(Closed Loop) ❑Tracer LOG attach ndditionnl sliaet ff-------❑Geothermal(I•leating/Cooling Retum) ❑Other(explain under#21 Remarks) DEscau"PION( ek I e, rniii stu era,ft. 1) So I C
4.Dsllc%Ve1l(s)Completed: 3-2 2 Well IDH fr. S ft. C I
Sa.1i'cll Location:
) It. > ft. L
5/c y fL ft.
Paciliiy/Owner Namc pncility 1?4(ifnpplicable) ft. ft. ,
l
i a^.._.. [Z a j*^ 4 Rd 4y°�ee�-D rr)� �� e 64�5 15)
Physical Addicss,City,and ZIP17
21.REMARKS
County Parcel Identification No.(PIN) c _ r 1
. 'T:r3vl�:1 i fa:• `.�er.31�f1.1
5b.Latitude and longitude in degrecs/minutes/seconds or decimal degrees:
(irwall field,one 1nViong is suff,cical)
22.Ccrlificaf
G:Is(are)the ivell(s): ®Pet•nlnnemt or• ❑T61iiporary Signature orCertifed Well Contractor 2
Dale
Bysigning this form,/hereby certt&that the ire11(,r)was(n•ere)coieu-ncted in accordance with
7.Is this a repair loan existing well: Dyes' i or ;;U"No 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200)f•ell Conviii(crion Standards and that a coP),
IJYlils is n repair,fill ail/known hall construction ii frirutailnii niid eaplaia the❑ann•e ofdie afthis record har been provided to the troll oit•ner.
repoir under 1121 remark sectioit or on the back ofdds fornr.
' ' ,1 1,.. 23.Site diagram or additional well details:
3.Fol'Geopi'obe/DPT or Closed-Loop Geothermal Wells having die same You may use life back of this page to provide additional well construction ittro
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See over ill Remarks Box).You may also attach additional pages if necessary.
drilled: i .
L'1'olal well depth below land surface: 0_ �:),US 24.SUBII4ITTAL INSTRUCTIONS
(R)
parnndtiple 11•e1/.r list all depths/fc/yjercat(evaniple-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
1 M1"
10.Static iva let,level below lop ofcasing; �y (ft•) 24a• For A11 Wells: Original form to Division of Water Resources (DWR),
lfirater level is abate casing,use"1 'r Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Borehole diameter: V (ill) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
12.1Vc11 cous(ruclian method:
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
Ox.ringer,rolary,cable,direct push,etc.) 24e.For Water Supply and Open-Loop Geothermal Return}Yells'Copy to the
county envtrotnmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells mroducing over 100,000 GPD: Co to DWR,CCPCUA
13a.Yield(gpui) ! Method of test• Permit Pent Program, 1611 MSC,Raleigh,NC 27699-1611 PY
13b.Disinfection type: HTH 1 lb.
YP Amount:
Pont GN'-I North Carolina Department of Environmental Qunlity-Division of Water Resources
Revised 6-6-2018