GW1-2023-01224_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
K.WATERZONES.
Well Contractor Name EO�IO DESCRIPTION
3441A /70`
NC Well Contractor Certification Number
15o OUTER CASING for am -case wells OR LINER if a r licable
NW Poole Well and Pump Company FROM TO DIAMETE2 THICKNESS cable)
Company Name l ft. � ft' d
/ I,' / 16.INNER CASING ORTURIN,G rwa eothel closed-too
2.Well Construction Permit#: �W— CS 7661 z—Z02 z FRO51 TO DUATETER, I THICKNESS I I MATERIAL b
List all applicable it-ell construction pertnits rt.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 D IAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. fr. ;n
❑Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft. in.
❑hldustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑ n- ate
Non-Water ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
r Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well:
tt.
❑Aquifer Recharge ❑Groundwater Remediation ft.
❑Aquifer Storage and Recovery ❑Salini Barrier 19:SAND/GRAVEL PACK if a licable
�' FROM TO MATERIAL EDIPLACEMENTMETIfOD
❑Aquifer Test ❑StormtvaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) []Other(explain under#21 Remarks) FRoat .TO DESCRIPTION color,hardness sail/rock • e, rain size,etc.)
ft. ft. ^C
4.Date Well(s)Completed: -oZ( 22 Well ID# ft. 7 ft.
5a.Well Location: " ft. v ft.
it. it.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
I 13" 6—C r'KW .�5 LU/w n, IZ �,tjet�L�li>. ft. ft.
Physical Address,City,and Zip „, N L 0 7S$7 ft. ft.
ct LX_ 211 REAVIARKS
t
County Parcel Identification No.(PIN) (rkft7W ft.-n PraC3c %ng Uni','
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) C� �jO� Q� 22.Certiffcat'
ht-4 to-/ 1 N � v., {OU V W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertffied Well Contractor Date
Dysigning this form,1 hereby certify ilia'the svel/(s)"'as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes;l or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conulniction Standards and that a copy
Ifthis is a repair;fill out knouvt well construction Nnforinatlon and explain Ilia nature ofthe oft/is record has beenprovided to the well oumer.
repair under#21 remarks section a•on the back of this form.
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 '
(5 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `-, tt.
1--or multiplewells list all depths ifdierent(example-3@200'and 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: d ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If,rater level is above casing,use"+� ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and O en-Lao 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 WEi.iR ONLY:
24d.For Water Wells aroduciRe over 100,0"GPD: Copy to DWR CCPCUA
13a.field rn BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
(gP ) D4ethod of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018