GW1-2023-01227_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW 1) ForInlernal Use Only:
I.Well Contractor information:
Landon Phillips
14.\VATER ZONES
WellConnlrnclor Narnne FROAI TO DESCRIPTION
3441 A 6 to "I.
G�� a' _
NC Well Conlrnclor Ccnification Numbert/r(^ ft. •
15.OUI'ER CASING for nnulll-cnscd veils OR LINER If n n nlicnhlc NW Poole Well and Pump Company FRO51 1'0 UTAM1IETER TIIICICNESS MATERIAL
Company Name ¢( ft. f�V
/ 16.INNER CASING MCI LUBING cothcrntnl closed-too,
2.Well Construction Permit 11: f'Z���D S� - ZOZ 2 FROM 1'o DIAME'I'Ett THICKNESS MATERIAL
0V all applicable well conslraclioll pariah,0.a.UiC,Coll, S/a/e,Parlance,elc.J ft. ft. - in.
3,Well Use(cheep well use): ft. ft. fn
FE3G3.'.dieU,',',',',,'1
t y Well: 17.SCREEN
grlural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑1vlunicipal/Public fr.
(l•leating/Cooling Supply) residential Water Supply(single)
( ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared)
18.CROUT
❑Il7i atioll ❑Wells>100,0003PD ITROM TO MATERIAL EM1IPLACENENTMETiIOD&AMOUNT
Non-Water Supply Well: rt. r fr. -gel 6❑Monitoring ❑Recovery Cr. rr.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and ltecovcry ❑Salinily[3arrier 19.SAND/GitAVELPACIC ifn licable
M
M1IAT IUAL E1s1P[ACEM1IENTMETIIOD
❑AquiferTcs1 ❑S1onmvaterDrainage❑Experimental Technology ❑Subsidence Control ft.
❑Geotliertnal(Closed 1-t1Op) ❑77iicer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(1-leating/Cooling Return) ❑Other(explain under 921 Remarks) I FROM ro DEscltlrTION coot I,arane„,em,vck r n rnl,,,lze etc.
nn�/ nnllH 6) ft. aft. Joe s o,i
4.D:Ilc1\Icll(s)Colllplcled: '`2'2!� Wclll ft.
Cw ft. � i
511.Well Location: OU fr.
rG n, 1 •e+
I'acilily/Owner Name facility,1D#(if appliicable) ft. ft.
S
Physical Address,City,and Zip
('J(I tce 21.REMARKS
County PnTccI Identification No.(PIN)
5b.latitude anti longitude in degrees/minules/scconds or decimal degrees:
(ii'well field,one IaVlong is suliicicnQ "
'h(_rq��0� h 22.ccrlificat•
f 1Q (� N �%mo W
6:Is(grrc)the 1vc11(s): ®Pcrulanent- or ❑Tcripornry. Signature ofCcnifted Well Contractor `-- Doc
By signing Ibis forms,I hereby cerlifY that file well(-)was(were)consrrnded in accordance trilh
7.Is this a repair to gill existing Nell: ❑Yes I.or, LnNo i5A NCAC 02C.0100 at,15A NCAC 02C.0100 Wall Carsrrucdon Standards and that a copy
IVINT is a repair,fill out known n•e/1 construction hi/oiamrlon mid explain ilia nature ofrhe afthls record har been prodded to ilia mall otr•ner.
repair utrda•1121 reant,ks section al-on the back.ojthds fang.
23.Site diagram or additional II•cl!details:
3.For Geoprobe/DPT or Closed-Loop Geotherilial Wells having die same You may use the back of this page to provide additional well construction info
coilslructiou,only I GW-I is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: t
f' 24.SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: (ft.)
Fa•nnrbip/c wells list all depths!f el&rent(example-3 tg 100'anda 1 100') Submit this GW-1 within 30 days Of wcll completion per file following;
i
10.Static hater level below fop of casing: (fl) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I/'nand lard/is abovecrrsing,use"•�" r-. information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole.dianater: w tilt) 24b.For Injection\\'ells:Copy to DWR,:Underground Injection Control(IUC)
12.Well construction inctliod: ,
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,roinry,enble;direct posit,etc.) 24e.For Water SumpiV and Open-Loop Geothermal Return Wells'Copy to lice
county environmeulal it depmimcnt of the county where installed
FOR WATER SUPPLY WELLS ONLY:
/�1 • 24d.For Water Wells roducin•over 1U0 000 Gl'D:Copy to DWR,CCPCUA
13a.Yield(gpul) GI(/ Method of test: Blow Permit Program,IGl 1 MSC,Ka eigh,NC06-99-"0'0161 1
13b.Disinfection t HTH 1 lb.
YPe; Amount:
i
Donn GW.I North Carolina Deparuncnt of Environmental Quality-Division of Waler Resources Iteviscd 6.6.2018