GW1-2022-03491_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD.(GW-b For Internal Use Only:
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1.Well Contractor Information:
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Landon Phillips .14.WATER ZONES
Well Contractor Name " FROM To DESCRIPTION/6 Q
3441 A
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NC Well Contractor Certification Number 15.OUTER CASING.for moltiV,¢ ed we OR LINER ira licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
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Company Name _ z r
( pO � 16.INNER CASING ORTUBING(geothermal___lclosed-too
2.Well Construction Permit#: l./ 1- '� 1 t '7` FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable,cell consrruc0oit permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In
Water Supply Well: 17:SCREEN. ;
FROM . TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. R. I in.
❑Geothennal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyNVell: ft. 30 ft. �lz�ToNlTy' SON E3�
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormrwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary).
FROM TO DESCRIPTION color,hardness soillruck type,grain size etc.
❑Geothennal(Heating/Cooling Retuni ❑Other(explain under#21 Rema±!1_1 ft. ft.
4.Date Well(s)Completed: o Well ID# ft. ft.
5a.Well Locaation:/ / ft. ft./till/L'J//✓G E 1 V rL ft. i
Facibly/Owner Name Facility ID#(if applicable) ft. ft.
L /LGt%V :7N�c ft. ft. MAR 2 2 202?
Physical Address,
/Als,Cii�ty,,and Zip /q�/� 7 Q KS
ft. ft.
F�6,i KL` S—I I 3 !—� �l� 21 REMAR
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field;one lat/long is sufficient) 22.Certificat'
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6.Is(are)the well(s): ®Permanent or ❑T�eemmporary Sig atureofCertified Well Contractor ` Date
Bysigning this form,I hereby certify that the)veA(s))vas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0100 or 15A NCAC 02.C.0200 Well Construction Standards and that a copy
ffdais is a repair,fill out Mran-it ivell construction information and explain the nature of the ofthis record has been provided to the ivell owner.
repair under#21 remarks section or on the back of this 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 info
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 necessary.
drilled: ?? 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For unihiple wells list all depths ifdiifferent(exmuple-3 a200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
1.0.Static water level below top of casiug: (tt.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1j)rater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:_ (1n.) 24b.For Inlection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NCi27699-1636
12,Well construction method: 24c.For Water Supply and Open-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental heat department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducine over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) ✓U Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb. S
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6.2018
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