GW1-2022-07750_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW 1) Por Internal Use Only:
I.Well Contractor Information:
Landon Phillips
14,WATER ZONES
Well Conlrnclor Nano FROM TO DFSCRIPTION
3441 A 6 ft. 14 s ft. 10
NC Well Cuntractor Ccnifirntimn Number ft. ff.
I -OUTER CASING for nm111-cased vplll OR LINER if n s dirnblc
NW Poole Well and Pump Company FROM MATERIAL
D)nnI,FTER TIIICICNESS
Company Name t l ft. a p ft. / ,In. { n1A A RIAL
q 16.INNER CASING OR 7•UBING cotliernrnl closed-too I
2.Well Construction I'erinit III!: 58 /b� FltOnt TO DIAntETElC THICKNESS MATERIAL
List all npplicahle well cortro•ucrion permits(i.e.UIC,Coungt State, Irariance,etc.J
3,Well Use(cheep well use): D. ft. in.
F0111d
ter Supply Well: 17.SCREEN
gricultural rnonl TO DlnmerER s1 orslzE nnclwess nlnrcrtlnL
❑Municipal/Public
colhermal(I Icating/Cooliag Supply) Residential Water Supply(single) r 5c L L/O G
ff. ft. in.
ustrial/Commercial ❑Residential Water Supply(shared)
Olrri alion 18.GROUT
❑Wells> IOO,000GPD FROM TO MATERIAL EMPLACEMENTRIETIIOD&AIIIOUNT
Nou-Walcr Supply Well: 1 ft. 20 ft.
❑ onit Moring ❑Recovery / I O d
Inject io I Wc1l: fr• ft.
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recover 19.SAND/GRAVEL PACK ifn r Iicnbie
Y ❑Salinity Barrier FROM TO nIATEIOAL EnIPLACEnIENTnIETIIOD
❑Aquil'cr Tcst ❑Slonnwater Drainage ft. /4'y ft. .C"1( �
❑Experim Technology ❑Subsidence Control ft, ft.
ental Technolo J )CJ IC
❑Geothermal(Closed Loop) ❑'tracer 20.DIULLING LOG attach additional sheets if necessary)
❑Geothennai(l leating/Cooling Return) ❑Other(explain under 1121 Remarks) FROM TO DESCRIPTION color,kardttess solutock Ilpe,gmin slut etc.
7
Q A. a ft. TV f S��L
4.Date Well(s)Completed: /"�7`2 Z Well IUH ft.
5a.11'ell Location: fn. /.b G ft.
'S t I IY 1'1 lklnej n. J ft.
facility/Owner Name Pacilily ID4(ifopplicabie) rt. ft. Ht F a E
9S Ckck)I n itif�Y ZebtyJon NC a -7517 ft. ft.
Physical Addicss,Cnyii,and Zip ft. ft. M
Fft \{LI I !� 21.REMARKS
County jff0Parcel Identification No.(PIN) DUO AOG
t't DO
5b.Latitude: id longitude in(legrees/mintltes/seconds or decimal degrees:
(il'wcll field,one W/long is sufrIcicnl)
22.CcrlificRt'
l[IYL 9 N . '11 W
6:ls(nre)the ivelt(s): ®Permanent or ❑Ternpornry Signalure ofCeniftcd Well Contractor Dntc
By signing this form,1 herebiir cart f•that the u•ellO was(were)construcled is accordance with
7.Is this:I repair to in existing\yell: ❑Yes or *UNo I A NCAC 01C.0100 0 ISA NCAC 02C.0200 lVoll Con tnictiou Siaurlardt and that a cop),
Iflhis is a repair,fill ow known well conslr•uuion infor•nratinn and explain the nature ofthe ofiltir record has been ptvvitled io the well ouvrer.
repair under 1121 remarks section ar oil the back of drit form.
23.Site diagram or additional swell details:
3.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use life back of this page to provide additional well construction info
consuuuction,only I GW-I is needed. Indicate TOTAL NUMBER of veils (add'See Over'in Remarks Boa).You may also attach additional pages if necessary.
drilled: i
/ 24.SUBMITTAL INSTRUCTIONS
9.'1'ol:nl well depth below tend surface: (R•)
1`01-mnhiple vclly list all depihs ifd ercm(example-3 tt 200'and 1 ten l00') Submit this GW-I wilhin 30 days or\vell completion per file follolving:
10.Static water level below top of casing: V 24n. Por All Wells: Original form to Division of Water Resources (DWR),
//•a"ater•level Is above cas•Utg,lire^4 (ft') hifonnation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
I1.Borehole diameter: (III) 24b.Tor Injection Well
s:Copy to DWR, Underground Injection Control(IUC)
12.Well conslruclioi method:
Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rolary,cable,direct push,etc.) 24e. !LSuaE1j_and_Opcn-Loop Geotherntal Return Wells:Copy to the
fO R WATER SUPPLY N ONLY: coullty environmental ealt i department of the county where installed
IyCLL5
66 24d.For Water Wells producing over 100,000 GI'D: Copy to DWR,CCPCUA
13a.Yield(gpnn) Alcthod of test: Blow 1'ennrt Program, Jul I MSC,RRlelg i,NC 27699-1 61 1
HTH
1 lb.
13b.Disinfection type: Amount:
form O\V-I North Carolina Deparnnent of Envirotuneolal Quality-Division of Water Resources
Revised 6-6-2018