GW1-2022-07757_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
3441 A a 6
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weus)OR LINER if a licahle
NW Poole Well and Pump Company FROa1 TO DIA163ETER THICKNESS aATERIAL
Company Name Ct. OL ft. in. t �d tl �LcIJ /jC l_'1
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable it-ell comtrtciion permits(i.e.VIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. tr, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: It. C�o ft. (] ,U I✓ J)
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licalile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EaIPLACEMENT METHOD
❑Aquifer Test ❑Stormnvater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG Ottach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) FROM TO DESCRIPTION color,harduess soltirock type,grain size,etc.)
7 O ft. ft. ; i L
-O 4.Date Well(s)Completed: -Z` Well ID# ft. iL 06,y
r tL
5a.Well Location: l J ^'
Dct-U C' ALe,f ft. fL
Facility/Owner Name f Facility ID#(if applicable) ft. ft.
US o }��t I�U �i�/1 I C �c� F�( n MCP �11-. O ^ /1/C tt. ft. E i*
w
Physical Address,City,and Zip 62 7{o ft. ft.
''e- J 21.REMARKS t.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/secouds or decimal degrees:
(if well field,one hit/long is sufficient) L _ 22.Certilicat' t:
�y G0 N 7gt5�S5S �,
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCeitified Well Contractor s Date
By signing this form,I hereby certify that the nell(s)was(here)consiructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cop),
1(this is a repair,fill out known hell construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this jonn.
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 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 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5��' (fl') Submit this GW-1 within 30 days of well completion per the following:
For niuluple wells list all depths tfd &rent(exaniple-3@200'and 2@100)
]0.Static water level below lop of casing: t� y (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Stataler ic
a above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf 11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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
(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 Wells produciu�over 100,000 GPD: Copy to DWR,CCPCUA
13a.field(gprn) I Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
131).Disinfection type: HTH Amount: 1 lb.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018