GW1-2022-07676_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Weil Contractor Information: A
Landon Phillips " �'' lh V D
14.WATER ZONES
\bell Contractor Name A U+ ! FROM TO DESCRIPTION `
3441 A G f'' q.S rr' toG
iftf�ffir,+�f�?� �';4, ^N�?g Una 0 rt. ; rL S, S �+e
NC Well Contractor Certification NumberrJt."Q 60G 15.OUTER CASING for multi-cased wells OR LINER if a, licablc
NW Poole Well and Pump Company PRoat To UTAatETEa T...C.'. MATERIAL
Company Namc
.S n, AS'rr• I ian• I/8'd 01V
3 /�9t'� 16.INNER CASING OR TUDING cothernsnl closed-loon)
2.\Vell Construction Permit H: 0 )FROM To I DIAME•rER THICKNESS MATERIAL
List all applicable well construction perndts O.C.UIC,CoungS State,Iariance,eta) ft. ft. in.
3,Well Use(checlt well use): ft. ft. in.
Wafer Supply Well: 17.SCREEN
FROM TO UTAMETEIt SLOTSIZE THICKNESS MATERIAL '
❑Agricuhural ❑Municipal/Public
❑Geothermal(I Icating/Cooling Supply) JResidential Water Supply(single)
❑Industrial/Commercial Olicsidential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD ITHOnI TO MATERIAL E.MPLACEMENT111ETHOD&AaIOUNT
Non-Wat(crSupply Well: O rt. ft. •Tewrr t
❑Monitoring ❑Recovery tt. n.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. fr.
❑AgUlfer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ira rlicablcFROM TO ntATEIUAL E51PLACE51ENTMETIIOD
❑Aquilcr'I'csl ❑Slomiwater Drainage Q fr. fr. ti t:
o tR..-
ClEsperimenlal Technology (]Subsidence Control tr. H.
❑Geolhermal(Closed Loop) ❑'fracer 20.DIULLiNG LOG allach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DMIM"HOn color,hardness solllrock type, atin aize etc.
it. fr. rT
4.Dale Well(s)Completed: %VWell iDH fr. ft. J a h
5n.Well Location: n. S' ft, t"_ ISAA
o4&e, C ko G fr. ft.
I'acil' ,/Owner Name Pncility IDN(ifapplicable) ft. fr.
Physical Address.City,and Zip ft. ft.
Lp" 21.REMARKS A
County �`���"L Parcel Identification No.(PIN) " ( A R 6V jF-1 S� F L
5b.Latitude and longitude in degrees/miuufesk.econds or decimal degrees: %V C ✓
(irwell field,one latlong is suff cicN) Q� Q��/J 9 22.CcrlifiCaf
�OO N __(/.7 V Voo W 7//7//Pa
t:
6:ls(are)(lie m•eli(s): 1911erntaneut or ❑Temporary Signature ofCcrtficd Well Contractor ` Dmc
Uysigning this form,l hereby certd/i-that the well(r)u-as(were)corstr•ucae(l in accordance trill,
7.Is this a repair to an existing well: ❑Ycs or MNo 1SA NCAC 02C.0100 or ISA A'CIC 02C.0200 Well Consiniction Standarat and that a cop),
!f this is a repair,fill out knorn went construction itorntation and explain the itmttr•e of the ofihis record has been prawided to the u'eli owner.
repair under 1121 remarks section or on the back ofthis form.
23.Site diagram or additional wcll'dciaiis:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well colislruclion info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovel'in Remarks Box).You may also attach additional pages if necessary.
drilled: I
3
9.'ibL•,I w 0�well depth below land surface: fl.
For multiple uellc list aR depths{/dij2renr(e.vample-3 n 00'and 1Q100') ( ) 24.SUBMITTAL INSTRUCTIONS
Submit tlds GW-i within 3U days of well completion per the following:
10.Static water level below lop of casing: 3 0 f. 24a• For All Wells: Original form to Division of Water Resources (DWR).
hh'nnter level is above casing,use'•1'• ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
/ `
11.Borehole diameter' v (in.) 24b.For Injection 1Yclls:Copy to DWR, Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,INC 27699-1636
12.Well construction method: 24c.For Water Supply and O en-Loa Geothermal Return�Velis: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 1Vells Drodacc ,over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield rat BIOW Permit Program,IG11 MSC,Raleugh,jNC 27699-IGl I
(gl ) �s Method or test:
13b.Disinfection type: HTH Amount: 1 lb, j
Form GW-I North Carolina Department of Enviromnental Quality-Division of Wnter Resources Revised 6.6-2018
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