GW1-2023-01218_Well Construction - GW1_20230127

WELL CONSTRUC'TI6N RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information: 1
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
� 3441 A
6 ft. Sft. Pal
NC Well Contractor Certification Number 15.OUTER CASING far multi-cased wells OR LINER if n Iicnble
NW Poole Well and Pump Company moM TO DIAMETER THICKNESS MATERIAL
-t-r ft. ft. in.' fCi/ Larl11�
Company Name 1 66
/ o L 7'��2 1G.INNER CASING OR TUiIING cothermal chried-loon)
2.Well Construction Permit N: � (?�J FROM I TO DIAMETER THICKNESS MATERIAL
1,i5t all applicable irell construction permits(i.e.UiC,:Coaaty,State,Parlance,e(c.) ft. ft.
3.Well Use(cliech well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft.
❑Geolhennal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
01rri ation ❑Wells>100,000 GPD FROM TO A TEItI EMPL EMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. li a
❑Monitoring ❑Recovery ft. ft.
Injection Well: tr, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if ri licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E111PLACEMENTMETHOD
❑Aquifer Test OStonW,waterDrainage
❑Experimental Technology bSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG nttacli additional sheets if necessary)
FROM TO DESCRIIrrION color,Imntoces,soilfroektype, rain sicc,etc.)
❑Geothermal(Hcating/Cooling Return). ❑Other(explain under 921 Remarks) ft ft.
4.Date Well(s)Completed: '!-1�-22 Well IDN ft. fL f(—y
Sri.Well Location:' d :, /.
rC04 El
Name "'"Facility ID#(if applicable) ft. ft. JA N 7
° 6J ft. ft.
Physical Address,City';and Zip ft, ft. �}� •��� ,�i r•
t,l�, y 21.REMARKS "
County �J WN"0t1� Parccl Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes%seconds or decimal degrees:
(ifwcll field,one IaUloi+g is su�cicnt)•.,,: ! lij;f�Is,',u'il'!'" 22.Certificati
95 Cp 25 13g N �JS:'t l `��� W
1. •nr.:u�,
6.Is(nre)(lie well(s):'❑1'ermnnent or ❑'Temporary Signature of Certified Well Contractor Date
lly signing ltiis form,l hereby certify that dloarell(s)was(here)constructed in accordanc e+rich
7.Is this a repair to an existing well: ❑Yes "br 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out knolrn+cell constriction information,and explain the nature of the of this record has been praNded to the imll ou-ner.
repair tinder 1121 renmrkr section or on the back of tlria forvri.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothe'rmal;Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate.TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:'+ ' .I ( s•p,l)t I;u
24.SUBMITTAL INSTRUCTIONS
9.Total welt depth below land surface: l S (fk)
For•multiple bells list all depths t(diorent'(exaniple;$(r 2,00',and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below to`p_.of casing: '' (f�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifn•ater level is above casing;rise 11," Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well coitsh ucton method!"Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I FOR WATER SUPPLY WELLS ONLY:
, 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) '_ Method of test:
BLOW Permit Program,1611 MSC,Raleigh,NC;27699-161 I
HTH 1 Ib. 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-201 E