GW1-2023-01223_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Irtemal Use only:
1.Well Contractor Information:
Landon Phillips
14.1VATER ZONES
Well Conlrnclor Name FRONI TO DESCRIPTION
3441A Id ff if 5- /v
NC Well Contractor Certification Number
15.OUTER CASING for naulll-cased wells OR L[NER if n t tlicablc
NW Poole Well and Pump Company FROM 1.0 ll1AMF.TVI TIIICICNESS MATERIAL
rL 11 3 ff• (o �0d�
Company Mine �
16.INNER CASING OR TUBING eollternml closed-loo t
2.Well Construction Permit!{: 07S-3GS FROM To D1AaIE1'Elt THICKNESS I htA'I'ERIAL
Ust all applicable well eacrn•metion perttths(.e.U1C,Coump,Stare,frarlance,etc.) ft. ff. in.
3.Well Use(clleci(well use): ft. ft. in.
Water Supply Well: 17.SCREEN
MOM ft.
DIAMETEit SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. H. tu.
❑Geothermal(1•Icating/Cooling Supply) residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri anion ❑Wells>100,000GPD ITROpt TO MATEItIAL F..AIPLACENIENTMETIIOD&AI1(OUN'r
NonrWatci-Supply tiltell: G rt.
❑Moniloring ❑Recovery ft. ❑.
Injection Well:
❑Aquifer Recharge ❑Groundwater Rem It. ff.edialion '
❑Aquifer Storage and Recover ❑Salinil Barrier 19.SAND/GRAVEL PACK ifnt licable
y Y FROM TO AIATMUAL I EhtrLACE•61ENTh1ETHOD
❑Aquil'er'l'esl ❑Stormwater Drainage fl. ft.
❑Lxperimeninl Technology ❑Subsidence Control ❑. fl.
❑Geollnernal(Closed Loop) ❑Tracer 20.DRILLING LOG friffachnilditional sheets ifnecessa
❑Geothermal(ideating/Cooling Return) ❑Olher(explain under 921Remarks) FRoat TO VLSCRa"rioN(coljorhararre,:eollfruckt e, rninaircalc.
fl. a fr. (o -So I
4.Dale Well(s)Completed: ?V-2Z Well il)f/ a1 rt. 90 ft. V CGnc�
a-a.Well Location: q_65 fL 15'ff.
ft. ft. 12. c 1.
Pacilil y/OwnerNamc ft. rt. 5 f N.,,�, •
> // �Fncilily 1llN(iCapplicable) �f
7( �'i1'uvrf a.� �r'�i e /n GJer/� �s a ✓1 ft. ff. J A N 2 .7
7071
Physical Address,Cily,and Zip ff. ft.
wat lCP 21.REMARKS t f15L"'•t w o :t : r. -- i✓,'. rX
County Parcel Identification No.(PIN) tit Pe Uj 3t.ft.7
5b,Latitude-"'Ill longitude in degreeshninules/seconds or decimal degrees:
(it'w2ellr field,
�one
�IaUl/onng is sunicicnf) 22.CCI'liflCal
J�S7�lJl_)�l 1�0 N W
. .
G:Is(:pre)the well(s): ®Permanent or ❑Temporary Signature ofCcrtifted Well Contractor Date
By signing this form6 l horoby cert!&Ilia/Ore 11,M(,r)it-cis(were)catsn•ucied in accordance with
7.Is this it repair to an existing well: ❑Ye$',:Or InNo /Sit NCdC 02C.0100 or 15A NCAC 02C.0200 11 ell Consmrcrion Slandardr and that a cop),
Ifthls lr a repair•fill out known well construction im(orvtmtlon aryl explain the nature oldie (kids record har been provtdeel to the well owner.
repair under 1121 reutar•ks soctlan or at(lie back of t ils form.
' ''' ' 23.Site diagram or additional well details:"
3.For Gcoprobc/DPT or Closed-Loop Geotharilinl Wells having die some You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwclls (add'See Over in Remarks Dolt).You may also attach additional pages ifnecessary.
drilled: t
24.SUBMITTAL INSTRUCTIONS
9-Total well depth below hand surface: 2q/r (ft.)
Fa•ualripie wells Niiall depths ifdjqcrent(example-3a200'and2«100') Submit this GW-1 within 30 days ohren completion per(be following:
10.Shtlic water level below lop of casing: Z Q (ft 24n. For All Wells: Original form to Division of Water Resources (DWR),
1/'traler level is above cashig,use^•�•�•. ) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 -
11.llovelnole diameter: (111•) 24b.For Injection NVells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.nuger,Well construction cable,
li, rcclltod: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to file
(i.e.auger,rotary•cable,direcfpush,etc:) I! county environmental health department of the county where installed
IrOlt WA'1'1'sR SUPPLY WELLS ONLY: 24d.For Water Well nrotlucine over 100,000 GPD: Copy to DWR,CCPCUA
13a.field(gpni) d Method of lest Blow Penn It Program, IGl 1 MSC,RRlcigh,NC 27699-I61 I
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Gnviroumentol Qunlily-Division oCWalcr Resources Rcviscd 6.6-2018