GW1-2022-07954_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
WellCanumctorName FROM TO DESCRIPTION
3441 A A2 rt. d55 ft. p/r"t
ft, ft.
NC Well Contractor Cerificaiion Number 15,OUTER CASING for mulli•casediwells OR LINER if a dicahle
NW Poole Well and Pump Company FROM TO DIAMETER( THICKNESS 111ATEHIAL
4-1 in. ( k I of
Company Nome 1
/r' •, 16.INNER CASING OR TUBING eo m theral closed-loop)
2.Well Construction Permit H: V yv_ Cam" FROM TO DIAMETER THICKNESS MATERIAL
list all applicable yell coatri(clion pennils(i.e.UIC,County,State,parlance,e(c.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
'Valet•Supply Well: FROMCE TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. i In.,
❑Geothermal(i leating/Cooling Supply) Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IRK alion ❑Wells>100000GPD FROl11 TO A ATERIAL EMPLACEaICNTNICTHOD&AMOUNT
Non-Wnler Supply Wcll: fr. ft. rvkP OUl2
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
10.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO IATERIAL I ENIPLACEb1ENTDie•TIIOD
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(sun It additional sheds if necessn
❑Geothermal(I-leating/Cooling Return) 00ther(explain under#21 Remarks) ]FROM To DUCRIPTION color,hardness soil/mck type,juvin sae,cic.)
6 fr. ft. TOP sd;t
4.Date Well(s)Completed:5 10�22 Well ID# R. C It— y
5a.Well Locution: fr.
ft. y a
ft.
Facility/Owner Nanic Facility iDN(if applicable) .
v 1L / 3►3(0 `)(w�f� .5 hw��o., r2 d wu r4 Forr�So yrr� ft. ft.
e,C2667
d G physical Address,City,and Zip ft. ft.
1n1L-(l~ 21.REMARKS
J.�
County Parcel identification No.(PIN)
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one liUlloonng is sufficient) t 0 a 22.Ccrlif If is
6.Is(are)the well(s): MPernanent or ❑Temporary Signature ofCeniBed Well Contractor ` Date
Dy signing t is form,l hereby certh,that the ivell(s)u•as(were)contstrucred in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No iSA NCAC 01C.0100 or iSA NCAC 02C.0200 Well Comiruction Standards and that a copy
ll this is a repair.fill on knouvn well construction b fornnallon and explain the nature of the oftids record has been provided to the well owner.
repair under#21 rewarkr.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 1 GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBNUTTAL INSTRUCTIONS
9.Total well depth below land surface: 30 R) Submit this GW-I within 30 clays of well completion per the following:
For ntuhiple wells list all depths ifd ylerew(example-3 rr 100'and 2@1001
Z (ft.) 24a. For Ali Wells: Original font to Division of Water Resources (DWR),
]0.Static water level below lop ofcasing: Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
lllrater level is above cosbtg,use
i
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Rotary Program,1636 MSC,Raleigh,NC(27699-1636
12,'Nell construction method: 24c.For Water Sunnly and Ovcn-Loop Geothermal Return Wells:Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health department of-the county where installed
FOR 1VATER SUPPLY 'ELLS ONLY: 24d.For Water Wells roducin I over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpni) 'lll/ Method of test:_BIOW Permit Program,1611 MSC,Raleig n;NC 27699-I61 l
HTH 1 Id. f
13b.Disinfection type: Amount
i
Form Gw-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018