GW1-2022-03606_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
I.Well Contractor Information:
Landon Phillips
14:R'ATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A qfwit L 5 ft. I 2-if) 4'1
6 Sft rr.
NC Well Contractor Certification Number �71' //
1&OUTER CASING for multi-cased wl s OR LINER if a Iicable
NW Poole Well and Pump Company FROM TO DIAMETER: THICKNESS cable)MATERIAL
Company Name tt
.1 .INNER CASING OR TUBING(geothermal closed-lomil
2.Well Construction Permit#: FR011f TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rue.I/IC,County,State,Variance,etc.) ft. ft. lin.
3.Well Use(check well use): fL ft. im
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. tt. is
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft rt. in
Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IRI ation ❑Wells>100,000 GPD FROM TO 51ATERUL EMPLACEMENT 111 THOD&AMOUNT
Non-Water Supply Well: ft, ft. tYl
❑Monitoring ❑Recovery ft. it.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if a Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control tt. 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 coelor,hardness soilfrock rain si etc.
0 IL Z. ft SU!` L
4.Date Well(s)Completed: " ' Well ID# ft. ft.
5a.Well Location: 9k
ft' ft.
a� m e s ft ft.
Facility/Owner Name Facility ID#(if pplicable) ft. ft. �„
ft ft ` o
Physical,`Address,tity,and Zip ft. ft.
21.REMARKS MAR 2
2022
County Parcel Identification No.(P1N) jf orprm:ion Praa=ina
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees: 1Dt"tQMOG
(if well field,one lat/loug is sufficient)
22.Certi
35.. 2 39 N ^ 7� fi cat'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the irell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No iSA NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well of mer.
repair under#11 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-1 is needed. Indicate TOTAL NUMI3ER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !''7 o 5- (ft.)
For multiple wells list all depths ijdierent(example-3@200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: L. G (ft) Information
For All Wells: Original form to Division of Water Resources (DWR),
Ifrrater level is above caste,use"y ,` 6 Information Processing Unit 1617 MSC;Raleigh,NC 27699-1617
re
,0 C J i
II.Borehole diameter: S (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 Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department bf the county where installed
FOR WATER SUPPLY WELLSONLY: 24d.For Water Wells producing over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield (1 Method of test: Blow Permit Program,1611 MS
(gPm) C,RaleighC,N 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
I
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018
II