GW1-2022-07745_Well Construction - GW1_20220819

WELL CONSTRUCTION RE CORD(GW-1) 77T
e Only:
I.Well Contractor Information:
Landon Phillips
14.WATER ZONES
\fell Contractor Name FROM TO DESCWT10N
3441 A It- la S-
ri. fr.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER trn iltcnble
NW Poole Well and Pump Company EMSCREEN
TO DIAaIETEIt THICKNESS MATERIAL
Company Name p- `
3 S p 9 L( L( SING OR TUBING eothermnl closed-loop
2,rVCIr COtIStt'It L'110t1 Permit H: FROMTO DIA IIF,TER THICKNESS MATERIAL
List all applicable,tell construction permits(i.e.UIC,County,State,variance,etc.) ft. in.
3.well Use(check well use): ft. in.
Wafer Supply Well: DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. to❑Geothermal(Ideating/Cooling Supply) Residential Water Supply(single) ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared)
,
❑IRA atiml ❑Wells>I nn 000 GPD FROat TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. e1U ft. go� nc Ole�
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinil Barrier 19.SAND/GRAVEL PACK if a licntile
y FROM TO MATERIAL I EMPLACEMENTAIETHOD
❑Aquifer Test ❑Storimvater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG Bonet addidonn0shee1s if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under u921 Remarks) r•Roal To DESCRIPTION(color,hardness,so Wrack t e, rnin size etc.)
p 0ft. d ft.
4.Dale Well(s)Connpleled:(p J —d a` Well IDH aft. 2� ft. C`C.-
,!it.Well Location: 2 ft. as' ft. A
tote (le- VtJrsh4— ft. fr.
q0
,acilily//gO�wner Name facility M11(ifapplicable) fr. ft.
✓ �frPd'.IO♦ e_ �1 'CAn,b0J/ ft. ft.
s
Physical Address,Ciq}and Zip ft. ft. AUG
9- 292Z
A_ 21.REMARKS Priaus"ftt.l UnA
County Parcel Identification No.(PIN)
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field,one fattlong is sufficient) 22.Cerli6cnl
N -- _7g. 3
fn:Is(irc)the\vell(s): ®Pen'mmnent or ❑Temporary Signature orCertified Well Contractor Dale
By signing this form,I hereby certify that the we//(s)u'as(ieere)constructed in accordance,rids
7.Is this a repair to au existing well: ❑Yes or IJNo ISA NCAC 02C.0/00 or ISA NCAC 02C.0100 Well Consintcton Stamlart/r and that n copy
#J this is a repair,fill out known well construction information and explal»the nature of the of t is record has been provided to the well oirner.
repair mufer P21 remarks section at-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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: I
24.SUBMITTAL INSTRUCTIONS
9.'rotal well depth below land surface: 010 ft
For inn tiple wells list all depths ifdijirent(example-3 200^^'and 1 a@100� ( ) Submit this GW-1 within 30 hays of Avell completion per the follorA•Ing:
10.Stnlic water level below lop ofcasing: C) 24a. For All Welts: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DW-R Underground Injection Control(fUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
i.e roger construction method: 24c.For lrtaler Su i and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,votary,cable,direct push,etc.) county environmental health department of the county where installed
FOR rVATLR SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gptn) \ Method of test: BOW Permit Program,1611 MSC,Raleig 1,NC 27699-161 I
13b.Disinfection type: HTH Amount: 1 lb.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018