GW1-2023-01214_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
i Landon Phillips la.wATERZONES
Well ContractorName FROM TO I DESCRIPTION
3441 A ft.
tfa6 e. tfgs fL 3 ,,,L
NC Well Contractor Certification Number .15:OUTEit CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
�, ft �So, ft. G8- in- C xwl
Company Name 0@
.16.INNER CASING OR TUBING(geothermal closed-lor
2.Well Construction Permit#: FROM TO I DIAIIIETER I THICKNESS I MATERIAL
List all applicable shell construction perm(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERLiL
[]Agricultural ❑Municipal/Public ft. TO
In.
❑Geothermal(Heating/Cooling Supply) )dResidential Water Supply(single) ft. ft. In
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑Irri atioll ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: 0 R. aO ft. /3f,�T.N t
7e ?
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft.
❑Aquifer Recharge ❑Groundwater Remediation ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19:SAND/GRAVEL PACK(if alicableFROM TO MATERUL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ` ❑Subsidence Coptrol ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothennal(Heating/Cooling Return) ❑Other explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soft/rock ty a min sint etc.)
6 ft. ft. a L
4.Date Well(s)Completed: S` —o'l��a d Well ID# a ft. �. ft.
S ND. cl�'
5a.Well Location: / / rt' aSa (rIq/�/=r L
l�M F7R CG,PRA 1, ft. SOS IL 6 ,1
e -
Facility/Owner Name Facility ID#(if applicable) ft. ft. ���.�•, 0_r 7�`. �„� It
F 1
S3/3 TfN Teti ROA ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat4ong is sufficient) "' 22.Certilica
'�5. y55 N 1 :-t52o� W v/a faa
6.Is(are)the well(s): ®Permanent or- OTei'nporary Signature of Certified Well Contractor ` Date
By signing this fornh,l hereby cert fy that the ivel/(s)iras(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes:. or ©No 15ANCAC 01C.0100 or ISA NCAC 02C.0200 Bell Construction Standards and that a copy
tfthis is a repair,fill out known well construction h foruiation and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
' 23.Site diagram or additionalwell 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'See Over' Remarks Box).You may also attach additional pages if necessary.
drilled: t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I 503..S ft.
For nndtiple wells list all depths!rdiereni(example-3@200'and 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
6.h.
10.Static water level below top of casing: U (ft) 24a. For. All Wells: Original form'to Division of Water Resources (DWR),
If water level is above casing,use"+" / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: Copy to DWR;Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Sum 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducina over 100,OR GPD: Copy to DWR,CCPCUA
13a.field(gpm) 6 Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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