GW1-2023-01246_Well Construction - GW1_20230127

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WELL CONSTRUCTION RECORD(GW 1) For Intemal Use ORIy.
I.Well Contractor Information:
Landon Phillips
14.WATER ZANCS
Wall Conlmdor Name FRO6I TO DFSCRIPTION
3441 A c 5oft• 15!rft.
NC Well Contractor Certification Number ff. ft.
NW Poole Well and Pump Company FR`OUT'ER C10S[NC form DlnMET rtells OTIl CKNESSfnIrIrMATERIAL
Company Natuc ft. 5'ft. in. ii
•0 c-1'+� CZG l v
16.INNER CASING OR TUBING cothcrnml closed-low))
2.Well Construction Irernlit t!:�'� -��y 1,Rohl TO DIA61FIE1i THICKNESS nIA'rER1AL
! l.tsl al/appUcable,rel/conrn nctiaa perruU.r(l,c.U/C,Courtgt SMt�arlance,etc.)zG ft, ft.
3.Well Use(checItwell use): in.
F�c
r Supply We
17.SCREEN
icultural ]FROM TO DIAMETEit SLOTSIZE THICKNESS n1ATERIAL
]FROM
ft B i,I
thermal(I"lea(ing/Cooling Supply) 1 H et_siciential Water Supply(single)
striai/Commercial I• ft. In.
❑Residential Water Supply(shared)
❑Irri anion 18.GROUT
Nou-11';dcrSupply ft.❑Wells>100,000GPD rHOhH TO h1ATEIoAL EhIPLACERIENTh1ETHOD& OUNT
�Vdl: ft. d
❑M D O oniloring ❑Recovery A 1.1
AM
F..tvll e Q"
Injection Well: ft. ff.
❑Aquilcr Recharge ❑Groundwater Remedialion ff. rt.
❑Aquifer Storage and Recove 19.SAND/GRAVEL PACK if n I lienble
ry ❑Salinity Barrier FRont To AIATEMAL Eh1PLAC
❑Aquilcr'I'cst ❑Slonu E6IENTh1ETHODwater Drainage fl. fL
❑L•xperimental 1'echnolo
gY ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑'tracer 20.DRILLING LOG Minch additional sbecfs if nccessa
❑Geothenmal(1-leating/CoolingReturn) ❑Other(explain under#2_1 Remarks) rltohl TO DESCRUTION cw1wrharuoe3s ui0aveklk r n rnrnstuetc,
ft. ft. TU
z 0
4.Dale Well(s)Complcletl: a l IUN � ff. ft. !' -
Sa.Well Location: ft. Gf ff.
Fvl r C ft. ft.
Facility/ rwler Naniw Facility ID#(if applicable) ft. ft.
_2Z_ct tr✓ .-h .5 iOl C
Physical Address,City,and ZIP ft. ft. -� J
WG�<« zL REMARKS r
County Parcel ldcnlification No.(PIN) to iii,.U;l t
r•A.r.
P.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irAvcll field,one InUlong is sllfr mlQ
zz.cel•uren r .
�7 lD N 'IV Z.
6:Is(are)(lie well(Is): [NPerolanent 01• ❑teirnpornty Signature ai[Ccrtificd Wetl Conuaclor �- c ^�/
, Date
BYsigningf/4form.lherebycerllf)•fhafthe1e1/(r)oh (were)colts rled in accordance lrith7.Isthisa repair loan Cxislln SYCII: ❑yeSl orl, 2!lNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conatr7rction Standards and that a copy
f/,this is a repab;fill makaou•n"ell carslracrion btf l:1italinn and eaplabt the mature wffhe afdrls record har beets provided m the well otruer.s•cpair under 1121 reutar•ks section or on the back oflhir farm.
' . '' ' ' 23.Site diagram or addilioual}yell details:
3.For Geoprobc/DPT or Closed-Loop GCOtllcflnal Wells having die same You may use the back of this page to provide additional well construction info
Construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.drilled: I
9.'1'olal well depth below laud surface: l9 �� (ft.) 24.SUBMITTAL INSTRUCTIONS
Fornnr/t1p/c Ire//,s list all depths lfdwerent(example-9a200'and2 100') Submit this GW-1 within 30 days ohvell t:ornplelion per the following:
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10.Slake Iva ter level below lop of casing: Z t^) (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
//'u nler level is abure cnsing,ase Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Iiorehole diameter: tilt•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and ODcn-Loon Gcotbcrnml Rclurll tiYelIs Copy to tine
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
,+ 24d.For Water Wells roducin over 1U0 000 GI'll: Copy to DWR,CCPCUA
13a.field(gpul) ` Method of test NOW Pemut Program, IG11 MSC,RRleig n,NC 27699-IG11
13b.Disinfection type: HTH 1 lb.
YP • Amount:
roan GW-I North Carolina Department o[Gnvirounlental Quality-Division of Water Resources Revised 6-6-2018
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