GW1-2023-01217_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Landon Phillips 14rWATERZONEs 11
Well Contractor Name - FROM To DESCRIPTION
3441 A .316 fr. 3" s fr. /5
NC Well Contractor Certification Number i p
"{
OUTER CASING:fkir- idti-casedvvells OR.LINER.ife licable
NW Poole Well and Pump Company FROM TO DLVAIL- n THnCKNESs D7AruRrer.
Company Name , 11 fL rn. G2s Gzul U
�[ 16:IMVER:CASIIYG.'ORsTUBING' "eollietmelclosed.lai
2.Well Construction Permit#: Q! L)C � `(! FROM TO DIAMETER THICKINESS h1ATERiAL
List all applicable well construction permits(i.e.UIC,Co nry,State,Variance,etc.) fit. tt In
i
3.Well Use(check well use): ft ft in.
Water Supply Well: 17 SCREEN ".
FROM TO DIMIEI'ER SLOT SIZE THICKNESS MATERIAL
❑Agricultural icipaVPublic ft. fit. in.
❑Geothennal(Heating/Cooling Supply) 2&�_sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) A&,,GROUT.
❑Irri ation ❑Wells>100,000GPD FROM TO MAMUAr EmPLACEMENTMETIIOD&AMOUNT
Non-Water Supply Well: it. 66- ft
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salini Barrier FROATND/GRAVEL PACK ifs 'h'cable, ,
q g ry tY FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Test Stormwater Drainage tL fa
❑Experimental Technology ❑Subsidence Control ft. m
❑Geothennal(Closed Loop) ❑Trace[ 20 DRILM ..LOG'attach:additioiiil'sheets:ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRDPTION(color,hardness,sait(rock type,grain size,etc.
ft. z ft. C G
4.Date Well(s)Completed: J f Well ID# Z ft. 7 ( ft. n- ,
5a.Well Location: ni '�I ft. q S ft. C,7 f�n,rt✓ --.
'1 ft. tt
Facility/Owner Name / Facility ID#(ifapplicable)
I
AN
�7 ft. rL 4 .i
v✓Gi:���� 12,. [�� .:': G.le/� i t
Physical Address,City,and Zip fit luzi
fit Inib l i:d:o 1 o'rr`^.:>,^, i%j 1!I
:21AIEMARKS',:'' J1P.`!�:% - n
County Parcel Identification No.(PIN) Used hardened steel drive shoe.
Sb.Latitude and longitude in degrees/mintifes/seconds or decimal degrees:
i
(if wellll field,/one]at/long is sufficient) " P;r,, '-7 22.Certilicati
3(o 0 V V.e 5� N -VU;✓ ! )6 1 i1 W
gt,IG-?-z
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
l;t'' By signing this form,]hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes' or 11No 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Mell Construction Standards and Ilia/a cope
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well outer.
repair under#21 remarks section or on the back of(his form.
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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:+ I''.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I I/ (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths rfdeerent(example-'.3@200'and 2@100')
_ 2 0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
If water level is above casing,use"+^If Processing Unit,1617 MSC,Raleigh,NC 27699 1617
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c For Water Suably and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) t'� �. / 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 6-6-2013