GW1-2023-01237_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14:WATER ZONES
Well Contractor Name FROII1 TO DESCRIPTION
3441 A /o fL I9 57 ft g
ft. fL
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DLIMETER THICKNESS aATERIAL
Company Name. .S ft. S ". in.
G,_ _ / Ul�_ �/ .11.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: (1 p'(,J FROnf TO D1AnIETER I THICKNESS I MATERIAL
List all applicable well construction permits ri.e.U ,Caumy,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): % fL in.
17;SCREEN
Water Supply Well: FROM TO DLUIIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. In
❑htdustrial/Commercial ❑ResidentiabWater Supply(shared) 18.GROUT
i ation ❑Wells>100,000 GPD FROM TO MATERIAL ENIPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft. !7 ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEIIIENT METHOD
❑Aquifer Test ❑Stormwater Drainage % m
❑Experimental Technology •❑Subsidence Control ft. ft.
❑Geotherrmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal Ae'ating/Cooling Return) ❑Other(explain under#21 Remarks) FRO51 1.TO DESCRIPTION color,hardness sollfrock type,grain size,etc.)
/ ft. ft. fity f O
4.Date Wells)Completed: Well ID# ft. �G ft. ��S-t—G M LX
5a.Well Location: " ft.
ft. fL
ty Facility ( applicable)
i
Facili /rOtvner Name Facili ID# ifpft. ft.
b $G L %P12fS S LA L fQ rt. ft. �..1„ffl
Physical Address,'City,an Zip' ft. ft. I 7 a 2L REMARKS t J
County Parcel Identification No.(PIN) :7-,o Int Q
Vnh
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if we
ll
field,one latAanng is sufficient) 22.Certitica'
ID Ckj j/ NI Vt�-l� ✓ W ( 11 roCd�
6.Is(are)the well(s): ®Permanent -or • ❑Temporary Signature of Certified Well Contractor ` Dale
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance frith
7.Is this a repair-to an existing well: [7Yes or InNo MA NCAC 02C.0100 or 15A NCAC 01C.0100 Mell Coruiniction Standards and that a copy
I/'this is a repair,fill out known well construction h formation and explain the nature ofhhe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
3.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: 1 '. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i i !I � t �, S (ft.)
For multiple hells list all depths rfdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
fi Static water level below top, casing: ( ) Information ProcessingUni 1617 MSC,Raleigh,lfu aver Jere/is above cashhg,use"+" �',.;� i k g ,NC 27699-1617 -
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:I 24c.For Water Supply and Ooen-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,gable,direct push,etc.) county environmental health department of the county where installed
FOR tii't\TER SUPPLY WELLS ONLY:,.'. 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
(gp )i Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield m � Method of test:
13b.Disinfection type: HTH. , Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018