GW1-2022-06403_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips .14.NVATER ZONES
Well Contractor Name FROM TO I DES rrr10N
3441 A !fo ft. +S % G
80 ft. ft / C &t
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft. 4 ft. in. lr Ca't•/
Company Name � •/ � !��
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable irell constructionpernrits(r.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply 1Ve11: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft.. ft. to
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
❑badustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rr1 ation ❑Wells>100600GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f" P ft. A,y%f�
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I E1IPLACEBIENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft. tt.
❑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) I
FROM 1.TO DESCRIPTION(color,hardness soillrock type,grain sin etc.
ft. a ft.
4.Date Vell(s)Completed: ~� Well ID# tt. '3 tt. A.V!> fi CIA-X
5a.Well Location: IT-ft. S ft. is eio.A,rTa
Facility/OOwcwnerName %? �ijt�/ / Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip VI&DFALI IV4 75"1/ ft. it. J U N 0 3
11.REIIIARIfS t..
County Parcel Identification No.(PIN)
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
«={ v i�i i0�111 Pr iOCEsSl lip J11
(if well field,d,one lattlong its sufficient) l , .-,,mac 22.Certifce J✓ t Le
Q, J I U N � ' ''1 q /,GS W L�C�¢�otDot�
v
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 'EN0 15A NCAC 02C.0100 or ISA NCAC 02C.0200 16e/l Construction Standards and that a copy
1/YIris is a repair,fill out known ivell construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or•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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 7� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓� (ft.)
For multiple wells list all depths Y dierent(example-3@200'and 2@100) Submit this GW-1 within 30 days Of well completion per the following:
3Q 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijn•ater I0.Static el is above casing,use"+"water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
er•level
11.Borehole diameter: v (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 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(gpm) V Method of test' Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 lb.
Forst GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018