GW1-2022-03614_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 I DESCRIPTION
i
3441 A a "fr z
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name
[ p 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: D-j/l)" d�'j ll 7 2- ZV�� FROM TO DIAMETER' I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC;County,State,Variance,etc.) ft. ft. iin.
3.Well Use(check well use): ft. ft in.
Water Supply Well: _ 17.FROM TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. I in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑$fi ation ❑Wells>100,000 GPD FROM I TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 fa 6 "- J r
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness soiUrock rain size etc.❑Other(explain under#21 Remarks) rt. ft,
4.Date Well(s)Completed: a' 2 Well ID# ft. ft. C V
Sa.Well Location: IQ
3 ft. 7 7 ft. M�.
rt. ft.
Facility/Owner Name i Facility ID#(if applicable) ft. ft. �.
t U
Ili l a q IV�W �,�h,1 ?J -0L� "A ft.
ftct_ ( .
Physical Address,City,and Zip AM d 7A ft. ft. IViF.A
i ►o {i 21:REMARKS
County CJL Parcel Identification No.(PIN) t0Ww 'n Pf¢cam"' Unit
LKIMIOUG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweH field,one
(]at/lon g issg sufficient) ( 2 22.Certifica tt:
_' '0 T,::) N :�i ✓� W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,l hereby certify that the lvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No ISA NCAC 02C.0100 or iSA NCAC 01C.0200 lVell Construction Standards and that a copy
If this is a repair,fill out M w own ell construction ii formation and explain the nature of die of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 toyprovide additional well construction info
construction,only 1 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: 2 2 / VL)
For multiple wells list all depths ijd fferew(example-3(200'and 2@100) Submit this GIN-1 within 30 days of Well completion per the following:
24a. For All Wells: Original farm to Division of Water Resources (DWR),
ijwater level is above casing,use
f Static water level below top of casing: (ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+r
11.Borehole diameter (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(MC)
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 of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
(gP ) 7
13a.Yield m L' Method of test Blow Permit Program;1611 MSC,Raleigh,NC 27699-1 6 1 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