GW1-2023-01247_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14::wATE>tzolvEs
Well Contractor Name
FROM TO. DESCRIPTION
3441 A fr. S n. ;L i
,NC Well Contractor Certification Number S OU.TER-CA SING iiiiu folfi-cased a.Wells"OR LINER'if a licable
NW Poole Well and Pump Company FROM TO DL1hfETER THICKNESS alATE[tlnL _
i ft 114/ rt 4 >n I ,o
Company Name .
G 7 .`16:`INNER'CASING:ORTUBWG; 'eilthet•malclo"sed-loo" �•
2.Well Construction Permit#: CrI�/ OOdAp3 4O?2 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. B: in. w I
CS
Water Supply Well: 17 CREEN FROM TO DIAIIfE'I•EB SLOTSIZE THICKNESS MATERuL
❑Agricultural ❑Municipal/Public ft. ft. ;n
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) fc
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 i'CGRObT }
❑Iri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT I
Non-Water Supply Well: 0 ' Zv ft. �� KGB tk
❑Monitoring ❑Recovery fa ft.
i Injection Well: ft. ft.
i ❑A ulferRechar a ❑GroundwaterRemediation
q g 19!`SAND/GRAVEL'PACK tfa lirktile
' ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO tifATERLIL EMPLACEMENT METHOD
❑Aquifer Test �::.i:.,r, gStoimwaterlhainage
❑Experimental Technology ❑Subsidence Control ft. ft.
` —--I
❑Geothermal(Closed Loop) ❑Tracer 20;DRILLING LOG attactiaddrfionalsheets if necessary):.
FROM TO DESCRIITION color,hardness soiltrocktype,grain size,etc.) f
❑Geothermal(Heatirig/Cooling Return) ❑Other(explain under 421 Remarks) I ft f6 T
O i
4.Date Well(s)Completed: Z 3 Well ID# ft. �U ft n F�
5a.Well Location'+ d: ft. ft. to f{Pi r dam, r{yam 4 1 ..
i. ;i�I,II i ft. f4, t
Facility/Owner Name Facility ID#(if applicable) ft. ft. stuej �{
d?'a M/1 �a � ft. fG'! tti0ifl^3'st sPra,
Physical Address,Crty,and Zip
� •t...yt'.Z<<e . : "41 REMARKS.r.r'
1
County !'' Parcel Identification No.(PIN) Used hardened steel drive shoe. _(
5b.Latitude and longitude in degrees/minutWsec'ouds or decimal degrees: --
(ifwell field,one ladlong is sufficient) 1".Nil 22.Certifieati
35 Bco�OR o N4 0 W
6.Is(are)the well(s)i'❑Permanent or ❑Temporary Signature of Certified Well Contractor `" Date
By signing this form,l hereby cert6 that the we//(s)was(were)constructed in accordance u1th
7.Is this a repair fo an existing well: ❑V6-'or 8No ISA NCAC 01C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a cgD.y
If this is a repair,fill out known well construction information and explain tine nature of the of this record has been provided to the+yell owner.
repair under#21 remarks section or on the back oJ'11d form.
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 into
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessari.
drilled:+
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J d (ft)
For multiple wells lis!al!depths ifdiiferent(esomple 3@200'and 2@100')', Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original forin to Division of Water Resources (DVdt),
10.Static water.level.below top of casing::" :' (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level isabove'casing,use
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC i
11.Borehole diameter. (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
�,. Rotary
12.Well construction method: I ' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to il-t
(i.e.auger,rotary,cable,direct push etc.) �,, county environmental health department of the county where installed
t,
FOR WATER SUPPLY WELLS ONLY:!
n- : 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCU_4
13a.Yield(gpro) Method of test:
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
�
136.Disinfection type: HTH Amount::1 lb.
Form GW-I i!•,i 1'1'!;North Carolina Department ofEnvinonmental Quality-Division of Water Resources, Revised 6-6-201 G
I^ t