GW1-2022-07746_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(G W-1) For Internal Use only:
1.Well Contractor Information:
Landon Phillips 14,wnrER ZONES
Well Contractor Name FROM TO DFSCRIPTION
3441 A 3 a, t(3 rL Q
NC Well Contractor Certification Number
5- n. -¢G R. 0 '' "
15.OUTER CASING for mulll-case we Is OR LINER iCn t licnble
NW Poole Well and Pump Company FnOal To DIAMETER TIIICICNESS aATERIAL
Company Name
/ 16.INNER CASING OIt TUBING eotherrnnl closed-loop)
2.Well Construction Permit#: } 7 l!�7 d FROM TO DIAMETER TTUCKNESs MATERIAL
/Jrl all applicable well constructiatr permltt(.c.UIC,Calmly,Slate,Parlance,etc.) rl. ft. in.
3.Well Use(check ivell use): ff. f, iry
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Ivlu�jci lTPublic 0 ft. 5:1-0. G( in. 04<
❑Geothermal(I Icnling/COoling Supply) esidentiai Water Supply(single) rt. ft. In.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri alion ❑WelIs> 100,000GPD FROat TO aIAT'EMAL EMPLACEDIENT•a1ETIt0D&AMOUNT
Non-WnlcrSupply Well: fi. t( rt. e-
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fl. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GILAYEL PACK if a r licable
❑Aquirer Storage and Recovery ❑Salinity Barrier FROM I TO I MAT'EIUAL I EMPLACENIENTMETIIOD
❑AquilcrTcst ❑StornwaterDrainage 0 ft. rt. 5" /
C1L-•xperimenlal Technology ❑Subsidence Control fl. ff.
❑Geothermal(Closed Loop) ❑lYacer 20.DRILLING LOG ollach ndditionnl sheets if necesso
FROM TO DESCRil"FION color,hardness sollhock t• e, rain sin etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) � fl. � rt. �,, "
a S"
4.Mile Well(s)Completed:`]-21 D ell ID# � ft. —� ft. C+^cii L(Ct
Sa.Well Location:
ft. rl. �` ( ! -
�• LL L fl. ft.
�•l I�T \'t a1L IA SrA
I;acilily/Owner Nanm Facility ID#(if applicable) ft. ft. v,
Lf IZCCtc r7frZt jZr_1 l /I-C
Physical Address,City,and Zip ft. ft. AUG
21.REMARKS ,
Counq' Pnrcel Identification No.(PIN) � �'L Pr0Ci4'R Wy%
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -VQIBOG
(ifsvcll field,one Inillong is sufficient) LL� ii jj 22.Cerlifteat• is 7.��5�11� N / L W
6:Is(arc)thewcll(s): Milermnnent or ❑Temporary Signature ofCcrifmd Well Contractor ` Date
Uw signing this form,I hereby cert j•than the well(v)was(were)constructed in accordance with
7.Is this a repair to fill existing well: 01'es or 814o 1SA NCAC 01C.0100 or ISA NCAC 01C.0100 11'ell Continiction Stanrlmrlt and that a copy
Ifthis is a repair,fill out known irell construction h!larniation and explain the nature ofthe ofthls record hat been prorlded io the irell owner.
repair under 011 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die 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 (idd'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 / _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ((e5 (ft.) Subni(t this GW-I within 30 days of well completion per the following.
Got unthiple trells list all depths!fdtgf rcnl(example-3@200'and 1Q100')
10.Slake water level below(up of casing: aZ U (ft.) 24n. For All Wells: Original form to Division of Water Resources (DWR),
It water level a above casing,ure"f. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(]UC)
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
(ix,auger,rotary,cable,direct push,etc.) county envirommenlal health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: W 24d.For Watcr ells Droducine over 100,000 GPD: Copy to DWR,CCPCUA
(gh ) Method of test:
13a.Yield inn BIOW Permit Program,1611
MSC,Raleigh,NC 27699-161 1
�U
13b.Disinfection(ype: HTH Amount: 1 lb.
Form GW-I North Carolina Deparintent of Environmental Quality-Division or Wnler Resources Rcviscd 6-6-2018