GW1-2023-01226_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-I) PorIntemalUse Only:
.1.Well Contractor Informntion:
Landon Phillips
14,WATER ZONES
Well COO IRICtor Nnine FROM TO DESCRIPTION
3441 A 00 ft. ud rft.
ft. rL
NC Well Contractor Certification Number
15.OUTER CASING for mutt(-cased wells OR LINER if a t llicable
NW Poole Well and Pump Company FROM TO D1ApIF,TER FT IICI(NCSS 51AT MAL
Company Name r ft. /vi S"ft. °� 1n. rva r / 'v
r" .• , 16.INNER CASING Olt TUBING cotliermnl closed-loot CJ
2.Well Construction Permit H: :�� �'V �076 a C rltOM1t TO DIAaiE'1'ER THICKNESS I MATERIAL
l.lriall applicable n•ell coirarructionPerudrs Ae.U1C,County,State,Parlance,ere.) ft. .ff.
3.Well Use(chccit well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIANETEIt I SLOTSIZE I T111CI(NESS MATERIAL '
❑Agricultuml ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l?Vesidential Water Supply(single) ft. ft. In.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑h'ri aliou ❑Wells>100,000 GPD FROM TO MATERIAL EhIPLACEM1tENTM11CTIlOD&AMOUNT
Non-11'alcr Supply Well: ®n.
❑Moniloring ❑Recovery ft. ft.
Injection Well:
ft. 11.
❑Aquifer Recharge ❑Groundwater Remedialion
❑Aquifer5loragcandRecovery ❑$alinil Barrier 19.SAND/GRAVEL PACK ifno lienble
y FROM TO a1ATEMAL I EMPI.ACEMENTMET1101)
❑AquilorTest [IS torulwalcrDrainage ff. ft.
❑L•xperimental Technology 17Sit6sidence Control ft. ff.
❑Gcolliermal(Closed Loop) ❑'Tracer 20.DIULLING LOG attach nddldonni slice is Irnecessn
❑Geothennal(l-leating/Cooling Return) ❑Other(explain under 921 Remarks) Afoot To DEscarrTioN color,hardness roiUruek type,grpilt size etc.
0 ft. d- ft. (ap r1A
4.Dale 11'ell(s)Compleled:-(0- w-2 Ewell II)1/ ff. I
ill.Well LocnlioD; G�b' R. �rft. 67wr✓I
pacilily/Owner Name facility IDN(ifapplicable)
IAR
71 o //0T�tu� yc, rl.
Physical Address,City,and Zip i ft. ft. Ural,
21.REMARKS t
County Parccl Identification No.(PIN)
5b.Latitude ant(Iaugiilide in degrees/nihniles/seconds or decimal degrees:
(irwell field,one lot/long is sufficient)
22.Ccrtifrcnl'
W
Z
6:Is(:lre)the well(s): (SI'erinanent 01• ❑Teliiporary Signature ofCcrtifned Well Contractor Dntc
11ysigning this form,(hereby cert!&that the wel(i)was(here)consirucved in accordance with
7.Is this a repair to an existing well: ❑Yes'.,,or.. *UNo 15A NCIIC 02C.0100 or 15A NCAC 01C.0100 Well Coarti7iction Slanfardr and that a copy
!J'this is a repair,fill as knau•a well construction hif6rula,flon and explain the nature of the afthis record har been provider(to the irel/onaer.
repair under 1111 rentarkr section or or the back of lhls form.
23.Site diagram or additional well details:
8.For Geoprobc/Dl'T or Closed-Loop Geotheriirnl Wells having the same You may use the back of this page to provide additional well construction illro
construction,only'l GW-I is needed. Indicate TOTAL NUMBER ofwells (ndd'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:
/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depllr below land surface:
For nmlrlple trellr list 0/1 depths ifd6getrnt(cva tiiiple-3 00'and 2 r@100') (ft) Submit this GW-1 within 30 days of well completion per the following:
10.Sltnf(c water Icvcl below to of cnsln 24n. For All Wells: Original Corm to Division of Water Resources (DWR),
1(iraterlevel is above casing,live 1,+ g' 2t� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
I1.1301-ellole diameter: �!/ (nil•) 24b.For Injection 1Vells: Copy to DWR, Underground Injection Control(IUC)
Rotary Program,1636 MSC,Ralcigh,NC 27699-1636
12.Well construction method: 24c.For WRler Suuly and ODcn-Loop Geothermal Return Wells:Co to the
(i.e.auger,Pantry,cable,direct puslt,'ctc:) county envtronmenlal health depnrtmenl of the county where installed Copy
FOR WATER SUPPLY WELLS ONLY: 241.For Waler 1Vells rotlucin over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield t mn BIOW Penn rt Program, 1 11 MSC,Ralcigh,NC 27699-161 1
(bi ) Method of test:
. .
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Deportment or@nvironutantal Qunlity-Division oCWnter Resources Revised 6.6-2018
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