GW1-2023-01245_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW 1
• Z For Intemnl Use OBIy:
I.Well Contractor Information:
! Landon Phillips
Well Contractor Name 14,IVATER ZONES
3441 A
FROM TO DFSCRIPTION
rt. rt. •
NC\vcll Cmaraclor Ccniffcalion Number, ft• ft.
NW Poole Well and Pump Com an p y IS.OUTER CASING for multl-ensedwells OR LINER ifnrilicnblc
FROM DIA51F,TER T111CKNESS ai7TERIAL
Company Natue + ft. ft. In. f<Ir�
C1I�,��r r.,,l:In L.G
Y v-,.jl� �� � 16.INNER CASING Olt TUBINGeoflmrainl closed-too r
2.Well Construction I'erinit H: 11 r•Ilont TO DIAMETElt THICKNESS MATERIAL
[.ir1 a/I appl/cahle well colarnvcttorr permits 0.e.UIC,Coltllp•,State,/rariance,etc.) ft. ff. in.
3.Well Use(chcCIE yell use): ft. rl. in.
"Pater Supply Well: 17.SCREEN
❑Agricultural MOM TO DIAME•TEIt SLOTSIZE TIIICICNESS afATERIAL
❑Municipal/Public R.
❑Geolhennal(1•lcaling/Cooling Supply) Residential Water Supply(single)
❑industrial/Comulercial ft. ft. in.
. ❑Residential Water Supply(shared)
❑Irri anon 18.CROUT
Non-Water Supply Nl'cil:
❑WelIs>100,000GPD FIt0a1 T IATERIAL ERIPLACEMENTAIMIOD&AN1011 f
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft• ft.
❑Aquitor Recharge, ❑Groundwater Remediation ft. It.
❑Aquifer Storage and Recovery []Salinity Barrier 19.SAND/GRAVEL PACK ifn licable
FIIom TO MATERIAL EMPLACEIIIENTMET110D
❑Aquilcr'I'cst ❑StornnvaterDrainage ft. ff.
❑Experimental Technolo
gY OSubsidence Control ft. ff.
❑Geolhennal(Closed Loop) ❑•.racer 20.DRILLING LOG nitach additional sheds irnecesiul
❑Geolhennal(l-leating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM re, DEscauI r oN 'clor Irnrdness selvtrocn type, rain size eta
ft. ft. J
4.Date 111ell(s)Completed:�a as Well IDH ft. / rt. C t�
5:I.Well Location: ft. ds ff. ^IpV�_
_ R It 9 s)Cy ft. `
Faclhly/Owner Nano FacilityIllN Ita ft. tf,
(' pplicable)
13136 qar�'� Sharron :Ww1G _ " ar y
ft.
Physical slit icss,City,mad Zip ^ �S ft. ff. t J
Lo�
•zI.REmnxtcs ,
Count' fhwtrl,:x< ra
Pprccl Identification No.(PIN) r9�• 1u�"•
i
5b.Latitude and longitude in[Iegrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/loag is sufficient) `'•' !
22.Ccrtilicaf
�Q () N o�q W
G:Is(arc)the{vCll(s): ®Ircrntauent or ❑Tt ilporar), Signature otCeniLcd Well Contractor Date
7.IS lh'IS a repair t0:111 existing{{'CII: ❑1'e$ Or, UJ'slgrdngthlsform,/herebycerlifJ•lhnitile well(r)was(were)constructe,lin accordance with
IJNU ISA N01C 01C.0100 a ISA NCAC 02C.0200!hell Colrsa710011 Standards and that a copy
Ifllris/r a repair,fill aut known well construction h+fm'nia(!ar and erplaln the nantre of the aflhls record has been prowled to the well oo7ver.
repair under 1121 renmr•kr section or on the back ofthls form.
23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop GeOIIIc ilh,MCils having the same You may use the back of this page to provide additional Weil construction info
construction,only 1 GW-i is needed. Indicate To'CAL NUMBER of wells (add'Sce Over in Remarks Box).You may also attach additional pages if necessary.drilled: t
rl,D 24.SUBMITTAL INSTRUCTIONS
9.Tolal well depth belon•land surface:_ 77 (ft.)
ra,•nndN/rle a clhs list all depths lfd eren!(e-raurple-3 a 2 0•and2ca 10oq Submit this GW-t within 30 days Orwell completion per the following:
10.Sbrllc water level below lop of casing:__�� 24n. For All Wells: Original form to Division of Water Resources (DWR),
!!'waterlerel is abase casing,trae"•1/• ,i, (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.Borehole diameter: b (ill.) 24b.For Infection Wells:Copy to DWR,Underground hljection Control(IUC)
12,Well conslructiol method:
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rolary,cable,direct pusI4 etc.) 24e.For Water Suppiv and Onen-Loon Geotbernwl Return 1YeiIs•Copy to the
county envlroluneulal health depaitmcnt of the county where installed
I1011 WATER SUPPLY!YELLS ONLY:
/. 24d.For Water Wells roducin over 100 000 GI'D: Copy to DWR,CCPCUA
13a.Yield(gpni) (p Method or test: BIOW 1'ennit Program,I611 MSC,Ra eigh,NC 27699-161 l
13b.Disinfection type: HTH . 1 lb.
YP Amoiint:.
Form GVV-I North Carolina Deparlment of linvirotrmental Qunlily-Division otwater Resources
Revised 6-6-2018
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