GW1-2023-01239_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW_D For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Nano _ FROM TO DESCRIPTION '
3441A 76ft O ft-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells 0 1 L[1 rR if n licable
NW Poole Well and Pump Company r•RODI TO DIAMETER TIIICKNESS alA7'ERIAL
Company Namc t r rt. I so rt. I & in. • /8 `a/(j, LJ
/�7�+�J�] ,N 16.INNER CASING OR TUBING cothermnl closed-loo t
J
2.Well Conslruclion Permit#: 4 - D t I %OC-W FROM TO DIAMETER THICKNESS MATERIAL
l.i.n all nppllcnhle u•eI1 corstrucrlon permiGr(.c.U1C,County,State,Irarlanec,etc..) Cr, ft. in.
3,Well Use(check well use): rr. rt. in
Water Supply Well: 17.SCREEN
❑AgriculWral ❑iviunicipal/Public FROM rr TO ft. DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Geothermal(I-lealing/CoolingSupply) Residential Water Supply(single) R, rt. tn.
❑Industrial/Commercial ❑Rcsidcntial Water Supply(shared) 18.GROUT
❑Irri alion ❑Wells>100,000GPD 17110111 TO MATERIAL EIIIPL EIIIENT111ETIIOD&AIIIOUNT
Not-Walcr Supply Well: rt. Z.2ft. O YQ/ v
❑Monitoring ❑Recovery fr. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Atuifer Slora aand Recovery ❑SalinitY Barrier
FROM TO MATERIAL I ERIPWCEDIENThIET1lOD
❑Aquifcr•1'cst ❑StornhwaterDrainage ft. fL
❑Experimental Technology OSubsidence Control ft. f1.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessa
FROM TO DE501I1'•1'ION color Itan7ues3 soll/rack type, rahu slu etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft ft
D7r
4.Date Well(s)Conlplelcd:7-4,'z2 Wall RDA ft. 3 ft. i y
5a.Well Location: ft. O ft.
1-0115
Facilily/Owner Name JJ racility Ill#(if applicable) ft. ft. ° 6 1 a. „ct
3�1f7 /'yl�lklf/1 ����hfC�4Gc I-,! A( erftA ft. ft. AN 7 2023
Physical Address.City,and Zip 76/6 ft. ft. Sr.x^: +:
21.REMARKS - r '�' ?•7 _f:;.]
County Parcel Identification No.(PIN)
5b.Latitude and longitude in rlegrecs/minutes/seconds or decimal degrees:
(irwell field,one lit/long is sufficient)
22.Ccrtificat
N -�8,.5 W .. - Z
6.Is(are)the well(s): ®Permanent or . ;❑Temporary Signature of Certified Well Contractor �` Dille
fly signbig drlsJorm,/hereby cert f'that ilia u'ell(r)u'as(were)constructed hi accordance,rrth
7.Is this it repair to:lit existing well: ❑YO, or InNo 13A NCAC 02C.0100 or ISA NCAC 01C.0100 Well Comtrtctlon Standards and drat a copy
//7h/s it a repair,full ow knasrit well construction it farmmtion and explain the nature of Ilia of this record has been pror8/ed to ilia well miner.
repair under 1121.rentorkr section or on ilia back of this form.
1 23.Site diagram or additional well details:
8.For Gcoprobc/DPT or Closed-Loop Geoliiernlal Wells having the same You may use the back of this page to provide additional well construction info
construction,only l GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over in Remarks Boa).You may also attach additional pages if necessary.
drilled: t
24.SUBMITTAL INSTRUCTIONS
For
well depth below sold surface: J (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nnrlNple u•elLr list all depths lfd�crcun(ernmrplc-3�00'anJd�2 r+!00')
10.Slltlic Ivatct Iet'cl below lop of casing: C�C/ (ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
1/\raicr lerel Is above casing,toe Y•r•" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Ilorehole diameter: (iu.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to tile
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
17011 WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin over 100,000 GPD: Copy to DWR,CCPCUA
13a.1 Yield nu ! Method of test: glow Permit Program, l6]1 MSC,RRletgh,NC 27699-I61 l
' (gn )
13b.Disinfection type: HTH Amount: 1 lb.
Corm GW-t •i North Carolina Department of Environmental Quality-Division of Wnler Resources Revised 6-6-2018