GW1-2023-01240_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
Landon Phillips 14.WATERZONES
Well Conlrncior Nano
FROM TO I DFSCRIPTION `
3441 A
86 ft. S n• it 7
NC Well Contractor Certification Number 15,OUTER CASING for mull)-cased we OR L[NER if n s licnble
NW Poole Well and Pump Company FROM TO D!ADIETER TIIICICNESS MATERIAL
f6 3 f6 In. rr 4(cJ.r^'��
Company Namc v
f w _�w 16.INNER CASING Oil TUBING eothermalclosed-loot
2.Well Construction Permit s;' (T 0 J C.FJZ FROM TO DIADIMER THICKNESS MATERIAL
List all applicable ire//construction permits rt.a.UIC,Coonry,State,lrnrlance,Cie.) ft, ft. in.
3.Well Use(check well use): rt. ft. is
Water Supply Well: 17.SCREEN
FROM TO DWIETER SLOTSIZE THICKNESS MATERIAL
❑Agriculhlral ❑Municipal/Public rr. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. ln.
❑Industrial/Commercial ❑Residential Water Supply'(shared) 18.GROUT
❑Irri ation ❑WelIs>100,000 GPD raohl I TO N ATERIALn EDIPLACEDIENTAIETnOD&AMOUNT
Non-Water Supply Well: rt. ft. �7✓ V✓n
❑Monitoring ❑Recovery ft. rt. y`
Injection lvcll: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRA\'EL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I E51PLACENIENTNIETIIOD
❑Aquilbr'fcst ❑StonnwaterDrainage ft, fL
❑Experimental Technology ❑Subsidence Control
❑Geothennal(Closed Loop) ❑'Tracer 20.DRILLING LOG attach additional sheets If necessary)
FROM TO DESCltlr'I'ION color,hardness soli/track I•re, rain siu etc.
❑Geolhennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fn fl. ft..
V t
4.Date Well(s)Completed:&-j7_-zz Well IDN ft. ft. C ,
ft.rr. O . ^fu
5n.Well Locution: �
D to nnC// D _0C.10er" rL ft. ci
Facility/Owner Nmnc Facility ID'd(ifnpplicable) ft. ft.
W f I IO w ft. ft.
't
SQr"'� /I/G
Physicist Address,City,and Zip � � ft, ft. l
23
(� 21.REMARKS
' 11Trus rS13�,1�1 . i =-%�•�i"� ril r
County Parcel Identification No.(PIN) 61 ",'aiD OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one Inviong is sufriicient) 22.CCrhfiea t' is
�51525► N _- �ao-� W - z
6:ls(are)the well(s): (Mernianent or ❑Temporary Signature orCcrtiried Well Contractor 1^` Dmc
Uy slgnbrg drir jornr,/hereby acts j•that the rverl(.eJ rrns(u•ereJ carstructed in accordance n•Irh
7.is this a repair to an existing well: ❑Yes or "UNo 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Consimetion Standards and shot a cop),
!f lhia!s a repair,fill out knotrn well coasts action it fnrmallan and explain she nature of the ajthis record has been prorided to Jhe urll corner.
repair under 1111 reorar•kr.section or on Ilia back of(N.T farm.
23.Site diagram?,or additional well details:
8.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
coilshuction,only l GW-1 is needed. Indicate TOTAL NUMBER ofwclls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
').'Total well depth below land surface: �� (ft.) Submit this GW-I within 3U days oCwcll completion per the following:
nnrhiple wells list all depths Icloercrtt(example-3�00'an 2 tc 100')
IU.Static water level below lop of casing: ()C.tJ (ft) 24a:.For All Wells: Original form to Division of Water Resources (DWR),
//'water level Is above casing,use t•" ]nformation Processing Unit,1617 MSC,Raleigh,NC 27699 I617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.11'cll conslruclion method: 24c.For Water Su 1 and O cis-Lao Geothermal Return Wells:Copy to the
(i.c,auger,rotary,cable,direct push,ate.) county enviromnenlal health department of the county where installed
FOIL WATER SUPPLY WELLS ONLY: ;'' 24d.For Water Wells producingover IUU,000 Gill: Copy to DWR,CCPCUA
13%Yield(gput) A•Iethod of test:
Blow Pennit Program,1611 MSC,KRlelglh,NC 27699-161 l
HTH 1 lb.
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Qunlily-Division of Water Resources Revised 6-6-2018