GW1-2022-07944_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
1\'ell Contractor Name At TO DESCRIPTION
3441 A Xds /So ft' lC
AT rt. 7�Fo f, zs NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company PRESN
TOe DN$IETER THICKNp1 MATEdR'IAL
Company Name dq� ft.�r ^`�t7i �� CASING OR TUBING eothermal closed-loo2.Well Construction Permit N: 1fW W / O To DIAMETF,R THICKNESS MATERIALlist all applicable well constrrrclion permits(i.e.UIC,County,State,Variance,etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply 11'eil: NTO DIMIETER SLO SSIZE THICKNESSAATERIAL
❑Agriculhlral ❑Municipal/Public ft. is❑Geotltennal(Heating/Cooling Supply) Residential Water Supply(single) ft. n.,
❑industrial/Commercial ❑Residential Water Supply(shared) .
❑1rTl at1011 ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. =N,Tea F O R tj=
❑Monitoring ❑Recovery rt. ft.
Injection Well:
ft.❑Aquifer Recharge ❑Groundwater Remediation ft.
❑Aquifer Storage and Recovery ❑Salini Barrier 19•SAND/GRAVEL PACK if a licable
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geotltemtal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additlonal sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sail/rack a rain sin e(c.)
����f' � ft. (t.
t.Date Well(s)Completed:/! Well ID# (t• J,9 ft. ! D f `
5a.Well Location: fL A ft- s`^tp •` QNi4 T 2
QNS 11 f C-7 S ft. ft.
Facilit /Owner Name ft. ft.Y Facility ID#(if applicable)
ft. 16
physical Address,City,and Zip (t. ft. f j r
li • _
(Hv�4k� 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certifteat'
rJ . S��q( N ^� I�q1 2:3 W
Signature of Certified Well Contractor ` o�
6.Is(are)the well(s): ®Permanent or ❑Temporary Date
By ,signing this form,I hereby certify that the irell(s)was(mere)constructed in accordance a ith
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 it ell Construction Standards and that a copy
It this is a repair,fill out known well construction h formarion and explain the nature of the ofthis record has been provided to the well owner.
repair under P21 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 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: 1
,s 24,SUBMITTAL INSTRUCTIONS',
9.Total well depth below land surface: (ft.)
For•multiple wells list all depths tfdifferent(example-3@200'and2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: J�
p`U ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If mazer level is above casing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
i.e Well construction cabe, method: 24c.For Water ROY and Oven-Loon 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 producing over 100 000 GPD Copy to DWR,CCPCUA
13a.field(gpm) O Method of test BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Porn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018