GW1-2022-07747_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW 1
. ) for InlernDl Use only:
L Well Contractor Information:
Landon Phillips
ISCREEN
TER ZONES
Noll Coi mclor Name TO DESCRIPTION
3441 A ft. j�S ft•ft. yL ft.NC 1Vcll Conlrnclor CertificatimR NmnbcrTER CASING for mull)-cased wells OR LINER if licnblc
NW Poole Well and Pump Company TO aIATERIAL
R. rr. im. A c,I V'Company Nanic ('l�Q ER CASING Olt I'UDING eoltserisiat closes)-loo i2.Well Construction Permit N: TO DIADIEIElt THICKNESS MATERIAL
Listall applicahle well convIraelion pernats(i.e.U1C,CmOtty,State,Irarionce,etc.) ft. ft.3.Well Use(cheep myell use): H. ft.Willer Supply Weil: EEN❑A ricullural TO DIAMETER SLOT SIZE TIIICI(NESS DIATERIAL
g ❑1vlunicipal/Public ft. H• itt.
❑Geothermal(1-Icating/Cooling Supply) Residential Water Supply(single) . ft. in.
❑Industrial/Comniercial ❑Residential Water Supply(shared)
18.GROUT
❑Irri allot ❑Wells> IOO,000GPll FROM TO MATERIAL' EDIPLACEDIENTAIL HOD&AMOUNT
Nun-11'ater Supply Well: 0 (I. ft. rz /a
❑Monitoring ❑Recovery n ft. 4,0
III•jectiolt Well:
❑Aquila Recharge ❑Groundwater Remediation ft. f(.
t9.SAND/GRAVEL PACK ifn-enblc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquil'er'fcst ❑Stormtvater Drainage ft. ft.
❑Experimental 7•echnology ❑Subsidence Control ft. ft.
❑Geolllerinal(Closed Loop) ❑Tracer 20.DRILLING LOG nllnch additional siieets if necessary)
❑Geothermal(l leating/Cooling IZetum) ❑Other(explain under N21 Remarks) 1 FROM TO DESCRIPTION color,liardncss solureck type,grall,ptzc cic.
ft. ft. � ` L
4.Dale Well(s)Conipleled:� "�Z Well IDN ft. 6 ft.
5a.Well
Location:
Locat ion: fl. tl-S ft.
S+ ) yY h )#J
It. ft. L/
Pacilily/Usvncr Name Facility IDN(ifapplicable) ft. ft. e.
�e 4Jlvn e. n. .`,� 5 _ _.
Physical Address,City,nnJ Zip ft. ft.
rf G n IC I /n z1,ItrmARICS At
County Parcel Idcntirtcaliou No. PIN �:
( ) fi9t-s�:tF3:1 PfoC Uflil:
Sb.La(ihule tuttl lotlgi(lide in degrees/minutes/seconds or decimal degrees:
(if,vell Field,one IaUloonnJg"issuiTrcient) % .�07 a�j 22.Cerlifiea(' C
N I� Kl! W
6:is(are)the well(s): ®Permanent or ❑Ternpornry Signature ofCcnificd Wcll Contractor Date
U),signing this form.I herebjr certl•that die rvell(t)ivos(were)consirucied in accordance frith
7.Is this a repair(0 an existing n'CII: ❑Yes or 6No 1 sA NCAC 02C.0100 or ISA NCAC 02C.0100'1Pell Consn•aclioll Ssanrlarrls and that a cop),
lf.drl s is a repair,fill oar knoll-Ifwell consinicdon infirniallon and explain the nanare of the of this record has been provided to the irell owner.
repair under 1121 renmrks section or on the hack of this form.
23.Site diagram or additional well details:
8.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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: t
n C' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: p J (R.)
Farnndliple irelis list all depths jd&reni(esaniple-3@200•anc12@1001) Submit this GW-I wilhin 30 days ofwell completion per(lie following:
10.Static m•ater level below top of casing: zo (fO 24n. For All Wells: Original form to Division of Water Resources (DWR),
I%unier/etc/is above casing,tise" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 -
I I.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: Rotary Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,r'olary,cable,direct push,etc.) 24c.For Water Su I and O en-Lou Gcothernin Return Wells:Copy to the
county environmental health department of the county w tere installed
FOR WATER SUl'1'L WELLS ONLY: 24d.For Water Wells roducin over IOU 000(;1, : Copy to DWR,CCPCUA
(gf
13a.Yield mt) Method of lest: Blow Permit Program, 161 MSC,Raleigh,NC 27699-I611
13b.Disinfection type: HTH 1 lb.
YP Amount:
Form G\V.I Nonh Carolina Department orrovironmental Quality-Division of Water Resources
Itcviscd 6-6-2018