GW1-2022-07952_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROA1 70 DESCRIPTION
3441 A 75- fr. ft.
(qu f. lr{S— fr.
NC Well Conlractor Certification Number
15.OUTER CASING for multi-coed wells 01 LINER if o licablc
NW Poole Well and Pump Company FROM TO DIAMETER T...CriNESS a[ATEIIIAL
ft. Sft. i in.
Company Name I I•
16.INNER CASING OR TUBING fizebtlermol closed-loon)
2.Well Construction Permit it: i✓) `� "'� - )10C` FROM TO DIAMETER THICKNESS MATERIAL
l.i.tl all applicable well construction perntfts(i.e.UIC,County,State,Variance,etc.) ft. fr. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: SCREEN17.FROM To DLAMETER SLOTSIZE I THICKNESS MATERIAL
OAgricultural ❑Municipal/Public ft. ft. in.;
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑In trial/Commercial ❑Residential Water Supply(shared) 18.GROUT
1i011 ❑Wells>100 000 GPD FROBI TO MATERIAL EMPLACEMENT METHOD&A51OUNT
Nou-Wafer Supply Well: d ft- U ft.
❑Monitoring ❑Recove 1st ,t e
fy rt. rr.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO a1ATERLAL I EnIPLACENIENTAICTHOD
❑Aquifer Test ❑Stonnwater Drainage ft. rt.
❑L-xperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG tatin h additional sbects if neccssa
❑Geothermal(I-Ieatin FROM TO DESCUPTIONcolor hardness soi Vinck te, rnht size,etc.)g/Cooling Return) ❑Other(explain under H21 Remarks) ._,
4.Dale111ell(s)Completed: G`)U� �. Well1Dit 0_11 ft. _�'6 ft. S C kca
'
` ft. ft. �x r
5a(.Well Lncnli`otr, i C3
VtL Palr�c\c ft. ft.
Facility/Owner Name facility ID#(iCepplicahle) ft. ft. r iVEDF
physical Address,Ci(y,and Zip ft. ft. P I J G J _
C)n i C-r—, 21.REMARKS
Cuunly Parcel Identification No.(PIN) Inn
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if,veli field,one IaUlong is sli icient) 22.Cerlificat'
N W
6:Is(arc)the well(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this fortn'1 hereby cer(h,that the trell(s)tras(mere)constructer!in accordance uvith
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a copy
1f this is a repair,fill out knorn well construction information and explain the nature ofthe ofthls record has been provided to the trek otrner.
repair under#21 remarks.section ar on the back of this fbrn.
23.Site diagram or nddilional 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-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBI4IITTAL INSTRUCTIONS
9.Total well depth belowland surface: ��3:>� (ft.)
For ninhiple,cells list all depths ifdijerent(example-3@200'and 2@1000 Submit this GW-1 within 30 clays of well completion per the following:
10.Static water level below top ofcasdng: �l/ (ft.)
ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
11 crater leve/is above casing,use"+" ) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
f I
11.Borehole diameter: AP (in.) 24b.For Infection Wells:Copy tojDWR,Underground Inieclion Control(TUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.ei.e.anger,rotary,cable.
,direct push,ern.) county environmental health department of the county where installed
FOR WATER SUPPLI'WELLS ONLY: 24d.For Water Weiis roducin over 100,000 GPD: Copy to DWR,CCPCUA
13a.1'igid(gpnr) Method of test: BIOW Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13b.Disinfection type: HTH Amount: 1 lb.
i
Form GW-I North Carolina Department oCBnviroamental Quality-Division of Water Resources : Revised 6.6.2018
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