GW1-2023-01238_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
f FROM TO DESCRIPTION
Well Contractor Name
3441 A Z50 ft' 2Go ft S M
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a dicablc
NW Poole Well and Pump Company FROM TO D.".TEd TIIICKNESs MATERIAL
•f-2 ft. 5S ft. G • fa' Ilip v
Company Name16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit H: FROM TO DIAAIFTER THICKNESS MATERIAL
Litt all applicable irell construction perndir(.e.UIC,Conitty,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. n. in.
Water Supply Well: 17.SCREEN
FROM TO - DLNIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 4unicipal/Public ft. ft. in.
❑Geotlicrinal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft ;n
❑industrial/Commercial []Residential Water Supply(shared) 18.GROUT
❑lrri atioll ❑Wells>100,000GPD FROM I TO 11IATERIAI ETIPLACEaIENTMETHOD&AMOUNT
Nou-Water Supply Well: O ft. S ft. 12—
❑Nloniloring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Retmediation
19.SAND/GRAVEL PACK If a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO4I TO 11IATERIAL EMPLACEaIENT51E171101)
❑Aquifer Test ❑StonmvaterDrainage ft. L ft.
❑Experitneinal Technology ❑Subsidence Control ft. ft.
❑Geothemlal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
PROM TO DESCU PTION Valor,hardness soll/rock type, min size,etc.)
❑Geothermal(I-leating/Cooling R to 1) ❑Other(explain under#21 Remarks) ft. ft. •
p� all G
4.Date Allell(s)Completed: �Z Well ID# `� � �• ft.
5a.Well Looc cS* �l/r/ ft.atiolnn,`,. ft. GtSS
V y�ale _ ft.
Facility/Owner Name pp Facilittyi H(ifapplicable) ft, ft.
'{/jr.'05 Rlu Poke Etle IVC Z;7Nd"`-? ft. ft.
1 hysic`I Addrgss,Ciq,and Zip ft. ft.
a i.-qs l:,rl +t C'_~.:5:r• Lr::
21.REMARKS
County Parcel Idendficalion No.(PIN) L
5b.Latitude and longitude fit degrees/minutes/seconds or decimal degrees: '
(ifwel`l field,one lat/llong is sufficient) $2.CerlifiCRC t:
01 1S1 N
G.•IS(arC)the lvcll(s): ®PCrn1allCilt or ❑Temporary SignatureofCcnifiedWellContractor Dal
Bysigidng this form,l hereby cer(yy that the irell(s)was(Isere)construcied hn accordance with
7.Is this a repair to an existing well: ❑Yes or nNol 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cominrcilon Standards and that a copy
1/This is a repair,fill out known well construction fi jonuatlon and explain the nature ofthe ofthis record has been provided to ilia well owner.
repair totter#21 remarks section or oil die back of this form.
I 23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells(laving the same You may use the back of this page to provide additional well construction info
Construction,only i GW-I is deeded. Indicate TOTAL NUMBER of wells (add Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBNUTTAL INSTRUCTIONS
9.Total well depth below land surface: ft.) Submit this GW-1 within 30 bays ofwell completion per the following:Far nwhiple wells list all depths jdierent(example-3 ter 200'and 2@100)
24a. For,All Wells: Original form to Division of Water Resources (DWR),
Static water level iglus top of casing: ?� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
[f/'water tenet is shore casing,use
11.Borehole dinmeter• r. (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.miger,rotary,cable,direct push,eta) . county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GPD: Copy to DWR,CCPCUA
�+ Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
131.Yield(gptti) J N•Ietlwd of test:
HTH i lb.
13b.Disinfection type: Amount:
f
Forin Gw-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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