GW1-2022-03580_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name
FROM TO rt. ft. DESCRIPTION
3441 A
o rt. 1 7 ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM-7 A TO DIAMETER. THICKNESS MATERIAL
46
fr. 13 DL It. i in CA ✓-
Couysany Name
16.INNER CASING OR TUBING eothervrat closed-loop)
2.Well Construction Permit it: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable hell construction permits(i.e.UIC,County State,Variance,etc.) ft. ft. in.
3.Well Use(check-well use): ft. tt' in.
Water Supply Well: iZ SCREEN.
FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural )iunicipal/Public ft. H, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. in.
❑bndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑]rri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. A ft. Mom T
❑Monitoring ❑Recovery ft. ft.
bijection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO51 TO MATERIAL EMPLACEMENT METHOD,
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks FROM To DESCRIPTION color,hardnesst soilfrock type,arein size etc.
p• 6 tt. J it. ..L
4.Date Well(s)Completed: Well 1DH ft. S ft' U } A
5a.Well Location: ft. 0 tt. T
C ,TAI Card LLC �� S f` fL 1
Facili /Owner Name I /f o(� ,Facility ID#(if applicable) ` ft. �.F �1�D
iRrk ro" S A l /R�IV�fi[�/V/O/11_) fL ft. MAR 2y 7
Physical Address,City,and Zip ft. ft.
f R"kLt/V 21:REMARKS Pr:;,.; unk
County Parcel Identification No.(PIN)
©WQMOC-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V
(ifwell field,one lat/long is sufficient) 22.CertificaI'
3C0• OS 911 N -"7�. L} �`J��P W
6.Is(are)the w•eil(s): ®Permanent or ❑Temporary Signature ofCeaified Well Contractor - Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0I00 or ISA NCAC 02C.0200 Nell Construction Standards and that a copy
(('this is a repair fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under a21 rentarks section ar on the back of this form.
23.Site diagram or additional well details:
3.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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R•) Submit this GW-1 within 30 days of well completion per the following:
rm•multiple wells list all depths ifdierent(example-3@200'andl@I00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: tw (R•) Information Processing Unit,16171MSC,Raleigh,NC.27699-1617
If water level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC'27699-1636
12.Well construction method: 24c.For Water Su I and O eri-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb etc.) county environments ealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin'over ILO000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm)�- Method of test: BIQW Permit Program,1611 MSC,Raleigh,NC 27699-16 1
13b.Disinfection type: HTH Amount: 1 lb.
i,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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