GW1-2023-01225_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
1.Well Contractor Information:
Landon Phillips 14MATERZOIVEsn r
Well Contractor Name FROM TO I DESCREMON
_
3441 A
S ft �, O ..
ft. ft.
NC Well Contractor Certification Number UUTER;CASING for mWh ca�ediwells OR DINER if ii'"licable
NW Poole Well and Pump Company FRoril TO DiAMF.TRR in. THICKNESS EATERIAL
ft. ft.
Company Name A117- � rUd S- Cia ✓
;16INNER GASINGOR T[TBIiYG"'eiitheimetelosed-ldo'
2.Well Construction Permit#: 1 O SS—G a7 — Z a 2 / FROM TO, DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
1 .a . .,...
Water Supply Well: 7iiSGREEN
FROM I TO I DIAMETER I SLOT SIZE THICKNESS brATERUL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18cGROUT
❑lni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. X? POCA r-
❑Monitoring ❑Recovery ft., ft.
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ft.
`�,19 SANDZGRAVEli PACK'ifs"'lickl'ile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
uiferTest 1
❑Aq ''0StormwaterDrainage
(r ft.
❑Experimental.Technology; t El Subsidence Control ft. %
❑Geothermal(Closed Loop) ❑Tracer FROM TO achDESrfiCRIPITON�olof hardness saiVrockgrain size
,etc.
❑Geothermal(Heating/Ccoling Retum) . ❑Other(explain under#21 Remarks) ft. ft.
l �o Sn
4.Date Well(s)Completed:_�1 -2, Well ID# a ft. 0 t't-
5a.�W/lell Location-.' go ft /
f i Z<'7yd�e'/i/ �i1>�✓lrG�t�� ;e.,e...,- �`a. Q� f•�..,6-
Facility//Owner Name Facility ID#(ifapplicable)
ft. ft.
7 Z Gl ( OS t!Gl vi d G%G�4 ,rs� Pic ft. ft. JAN 2 '7
Physical Address,City,and Zip ' , ft. ft. ^�
•21.'`•.RE5L4RKS � rs a ith-a^,]'.
Coun^-ty . Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lloong is sufficient) d: : 22.Certificati
,i.
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
_ L 1 i'I, By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes! or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
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 ivell ouwer:
repair under#21 remarks section or on the back of this firm.
I tl ,. 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:+
24.SUBMITTAL INSTRUCTIONS
i I'i t,. —0
9.Total well depth below land surface: (ft.)
Formultiple wells list all depths tfdi,�erent(example=:3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static waterlevel below top of casing: 2!J (ft)
If water level is above casing,use"+" Information Processing Unit,I617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c For Water Supply 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) Method of test
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
131b.Disinfection type: HTH Amount: 1 Ib.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018