GW1-2022-06929_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name fro ft S ft.
3441 A lJ
os ft �/Q ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and PUMP Company 1FROM TO DIAMETER THICK}Nf�E/S MAAWRIAL'I
V'/ ff. ,/'i ft. 6 is .!f/v V 4 L V
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATE L
RIA
in.
List all applicable well construcrion permits(r.e.UIC,County,State,Variance,etc.) fL ft.
ft. fL is
3.Well Use(check well use):
Water Supply Well: FROM
SCREEN
Waterpp Y FR011f TO I DIAMETER SLOT SIZE THICKNESS 11L1TERIAL
$Agricultural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑hrdustrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: Q it. O it. LNToMi7� O ^D
❑Monitoring ❑Recovery it. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a IicAble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Et11PLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. tt.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soill k type,grain size etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft ft G
�^f O o� Te 7 a
4.Date Well(s)Completed: Well IDI$. ft. ? ft. . A vb G tlk-
5a.Well Location: it. iis ft. A R �..t
/Y ilwe- T�RF Sv�aTo„�.,5 << < ft. ft
Facility/Owner Name �Facility IDN(if applicable) ft. ft.
Sa f�dCO/�'b ti 1 j�0 A D ft. ft.
Physical Address,City,and Zip �ONN��1 B..�*;.� NG ft. ft. 2JUN 2
FR/E,v k�r,✓ ';, 21.REMARKS
County Parcel Identification No.(PIN) w It;'1r YiOCES'Si'utj Ulm
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certiricat'
1�10 � N -- `79�&QCn 7 W 3 , VA
6.Is(are)the well(s): NPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that rite ivell(s)ryas(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 02C.0100 or 15A NCAC 01C.0100 if'ell Construction Standards and that a copy
Irthis is a repair,fill out known well construction information and explain rile nature of the ofthis record has been provided to the tve11 owner.
repair under 921 remarks section at-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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: (R') Submit this GW-I within 30 days ofwell completion per the following:
For multiple trells list all depths rfdocrent(example-3@200'and 2@I00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
]fu Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
[fvnrer level is above casing,use
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to IDWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental Us department of the county where installed
[13a.
OR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Oroducing aver 100,000 GPD:Copy to DWR,CCPCUA
GQ �— BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
Yield(gpm) y Method of test:
3b.Disinfection type: HTH Amount: 1 IIJ.
P
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources: Revised 6-6-2019