GW1-2022-03737_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i.Well Contractor Information:
Landon Phillips 14.1VATERZONES
FROM TO DESCRIPTION
Well Contractor Name � ft 2/6 ft -
3441 A
rt. ft.
NC Well Contractor Certification Number
I .OUTER CASING for multi-cased'nve OR LINER if a liable
NW Poole Well and Pump Company r•ROM TO DIMIETER T1ncKNEss MATERIAL
ft. ft. in.
Company Name s 16;INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:G—Lj S ZV Z 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable it-ell construction permits(i.e.UIC,County,State,Variance,etc.) L::�E
ft. � in.
3.Well Use(check well use): ft. la. ,
17.SCREEN,
Water Supply Well: FROM , TO DIAMETER i SLOT SIZE TIHCKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in,
❑Geothermal(Hcating/Cooling Supply) KResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL Eat ACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ✓"—
OMonitoring ❑Recovery ft. ft.
Injection Well: it. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
OAquifer Test OStonmvater Drainage rt. ft.
❑Experimental Technology ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets If necessary)
FROM TO DESCRIPTION color hnrdness spill_ck type, rain size,etc.
OGeothenmal(Heating/Cooling Return ❑Other(explain under#21 Remarks) G ft. ft. SG'j
4.Date Well(s)Completed: -Z Well ID# ft. ft. L1
51.Well Location: ft' !r i
tL ^
/ �—j k` tLr C
Pacilitl'/Owner Name Facility IDN(ifapplicable) ft. ft.
ft. ft. ,
Physical Address,City,and Zip ft. ft. MAR —
` 2L REMARKS r
Cormly Parcel Identification No.(PIN)
''• ,F.,_C._ :t�+Jig;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiield,.one
-llaattl�oug is sufficient) �^ r 22.Certificat'
7 ,1 N 7 W
6.Is(are)the n•ell(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing dtisyorni,I hereby certlyy that the u•ell(s)was(were)constructed in accordance iridt
7.is this a repair to an existing well: ❑Yes or ©No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 11"ell Consnvcnon Standards and that a copy
1J dris is a repair,fill out known hell constriction h jorntation and explain the nature of the oyttis record has been provided to due well owner.
repair under 921 rentaAs section or on the back oydds yornt.
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 toprovide additional well construction info
construction,only 1 GW-1 is needed. hldicate 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: �O� (ft.)
1--or nahiple wells list all depths iydiiferent(example-3(200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
1 10,Static water level below fop of casing: to 0 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft Information Processing Unit,1617 MSC,Raleigh,l�woter level is above rnsing,rase"+" ) g NC 27699-1617
I.I.Borehole diameter: (in.) 24b.For Itliection Wells:Copy t0'DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well cotsh rretion
auger,
(i.e.auger,rotary,
method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
ry,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
m1 f) Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.field
(gl ) k" Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Fomr G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018