GW1-2023-01236_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14:WATERZONES
FROrd TO DESCRIPTION
Well Contactor Name /o It /1 It• ' G
�. 3441 A ! ft. %
NC Well Contractor Certification Number .15i OUTER CASING for multi-cased wells OR LINER if no livable
NW Poole Well and Pump Company FROM IL TO ft.
DIAMETER is THICKNESS MATERIAL
S
Company Name. 16.INNER CASING ORT PB eothervral elosed-loop)
2.WCII CDIlStraell0n Permit#: FROM TO �11 THCKNESS MATERIAL
Litt all applicable hell constructionpermits(I.e.U ,County,State,Parlance,etc.)
fL UL
ft. tt. is
3.Well Use.(cliechwell use):
17:SCREEN
Water Supply Well: FROM TO DWIETER JSLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Publig ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
i anon It1ATERIAL EAIPLACEI1fENT I11ETffOD&MIOIJNT-
❑Wells>100000 GPD FRONI TO
Non-Water Supply Well: It. d tt. RE
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if a ticnble
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO51 TO IIIATERW. EQIPLACE111ENTNETIfOD
❑Aquifer Test ❑Stonnwater Drainage it. tt.
❑Experimental Technology ❑Subsidence Control ft. ff.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional.sbeets If necessa
FROM .TO DESCRIPTION color hardness sotllrock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft• fid So /
02
4..Date Well(s)Completed: O r� Well IDit ft. 26 ft. ST- 67
(t. 2GS ft 5a.Well Location;Cyo/A!�S ER hLfAuk et. ft. ,, .3�
—' 'Facility ID# tfa applicable) ft. ft. �
Facility/Owner Name tY ( pp )
ZAkE b JAN
P- it. it.
ft. tr.
Physical Address,City,an Zip o
" :" 21.REMARKS
t * i--taal in lira
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,oneella(t/l�onng is sufficient) -A22.Certificat' /[
Signature of Certified Well Contractor
J! Da e
6.Is(are)the well(s): ®Permanent or OTemporary
13ystgnnhtg dais jornn,l hereby certify that the well(s)was(irereJ constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 01C.0100 or 15A NCAC 02C.0100 HIM Construction Standards and that a copy
tt iris is a repair,fill out known'well construction information and explain the nature ojthe ojthis record has beery provided to the well owner.
repair under 921 remarks section or on the back ojthis fort. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Ovel in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (n') Submit this GW-1 within 30 days of well completion per the following:
Fa•nndtiple wells list all depths fdierent(example-3@200'and 2@100)
:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fr) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
otary
12.Well construction method: 24c.For Water Supply and Oben-LooD Geothermal Return At"!:
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: r. 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
X BIOW Permit—No—gram,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type; HTH Amount:
i
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018