GW1-2022-03508_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal)Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441A P0 fL j/ ft. S 7p;11"
ao
fL 'GSft. G/J.�
NC Well Contractor Certification Number 0
15.OUTER CASING for multi-cased wells OR LINER if a Hcable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
.f fL ' ft. i. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: f=�I IXJ�S� FROM I TO I DIAMETER I THICKNESS--t MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): fL ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) `�2esidential Water Supply(single) fr. ft. is
❑bldustrial/Commercial '❑Residential Water Supply(shared) 18.GROUT
❑bTl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 26) ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if a Hcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft fr.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return 00ther(explain under#21 Remarks) FROM To DESCRIPTION color hardness soiUrock a rain size etc.
4.Date Well(s)Completed: V 11�4ell ID# ft' G ft. w )(
5a.Well Location: L tr. 7,V S rr. �� r
ft. fr.
Facility/Owner Name Facility ID#(if pp'cable) ft' ft'
,��ll
I , Lzo !V� Hwy 7r I rL n
ft.
f
Physical Address,City, d Zip ft. -
�,(t�/q '7� 21:REMARKS
Count' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweU field,one lattlong is sufficient) 22.Certifreat'
X5
N 'J ' - W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,)hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0100 at-ISA NCAC 02C,.0200 Well Construction Standards and tlwt a copy
Ifthis is a repair,fill out known well construction i formation 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths it different(example-3@200'mad 2Q100) y P P g'
lU.Static water level below top of casing: Z(� (ft.) Information
For All Wells: Original forth to Division of Water Resources (DWR),
Ifwater level is above casing;use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-I617
11.Borehole diameter: (in,) 24b.For Iniectiog Wells:Copy to DWR Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 21699-1 63 6
12.Well construction method: 24c.For Water Supply and O en-loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m Method o[test Blow Permit Program,1611 MSC,Raleigh;NC 27699-1611
(gP )
13b.Disinfection type: HTH Amount: 1 lb.
I
Form GW-1 Notch Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2018