GW1-2022-07945_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Landon Phillips
14,WATER ZONES I
Well Contractor Name FROM TO I DESCRIPTION
3441 A Idof`' As f'' d G 'off
NC Well Contractor Certification Number
1,60 ft. s' G
15.OUTER CASING for multi-casedlwells OR LRVER it a livable
NW Poole Well and Pump Company FROM TO C DIAM TER THICKNESS MATERIAL
Ift. dl 7 fL in. 1� C•�/1p�Company Name • 9
_ 9 6$SFs 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: Q7o 1 FAOAt TO DIAMETER TIICKNESS MATERIAL N
List all applicable hell construction permits(i.e.UIC,Comity,Stale,variance,etc.) ft. ft. in.
3.Well Use(vied(well use): fr. tt. 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.
❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. ()6
❑Monitoring ❑Recovery ft. ft. 1j
Injection Well:
tt.
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT AIETHOD
❑Aquifer Test ❑Stormwater Drainage ft. H.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothernal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color hardness 9oiUrock e, rain 9iue etc.)
� tt. fr. To X>Svi L
4.Date Weil(s)Completed: Well ID# ft. ' tt. SjkyD
5a.Well Location:NA
Mti AP1010l S J�NG ft. tL
Facility/Owner Name Facility ID#(if applicable) ft. ft. �, $'� ? VJ
/Q S P7 TL`/V 77 y R1� ft. ft.
Physical Address,City,and Zip ft. ft. , ( Q •�
le�AKr
21.REMARKS t fi4t
Colmty Parcel Identi fication No.(PIN)
J•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one
rlatQ/long,is sufficient) �7a 22.Certificat
N f CJ �al _W O r 0 b a6
6.1s(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing Ills form,I hereby certt&that the we (s)was(were)constructed in accordance 4rith
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 02C i0200 Well Construction Standards and that a copy
It this is a repair,fill out known rue//construction information and explain the nature of the oftris record has been provided to the well owner.
repair under P21 remarks section or on the back of this fonn.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You imay also attach additional pages if necessary.
drilled: 24.SUBNHTTAL INSTRUCTIONS
9.Total well depth below land surface: r;03• ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@100) ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below lop of casing: (ft 24a. For All Wells: Original form: to Division of Water Resources (DWR),
\)baler level is above casing,use^+'• 20 ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 -
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR;Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12. Veer 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 departinent of-tile county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducin2 over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield ) BIOW Permit Program,1611 MSC,Raleigh,NC 27699-161 1
(gpm Method of test: i
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6•6-201 B
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