GW1-2022-07955_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well Contractor Information:
Landon Phillips
14.1VATER ZONES
Well Contractor Name FROM TO DESCRIPTION
s-f ft.
qP
3441 A o ft.
/o`t f ft. ;
NC Well Conlrnuor Certification Number ft. AIL
15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS AIATEIIIAL
.--
Company Name T
16.INNER CASING OR TUBING Neothermal closed-loot))
2.Well Construction Permit ff: FROM TO DIAMETER THICKNESS MATERIAL
List all olgAcable well consa-r 0011 perinils(i.e.U1C,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Willer SupplyWell: FROM To DLAAETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public o It. /ff tn. in. O e
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑11TI ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. a.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a lic:ible '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROAI TO AIATERIA I EAIPLACEAt ENT METHOD
❑Aquifer Test ❑StonmvaterDrainage rr. ��� tl. — 3 AvE C
❑Experimental Technology ❑Subsidence Control ft. A.
❑Geothernral(Closed Loop) ❑Tracer 20,DRILLING LOG attacb additional sbeeis If necessary)
FROM TO DESCRIPTION color,hardness soillrock type, rmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under f121 Remarks) tr. ft.
4.Dale Wcll(s)Completed: 5 ��10 _�COWell ID11 ft. ft.
a
5a.Well Location: ft. ft. § ',_v k
ft. It.
-
Pacilily/Owner Name Facility ID#(ifapplicable) ft. ft.
f54�O ZFBti L o.v. k A ft. ft. A r.,
physical Address,City,and Zip 4,
/Kc ft. ft.
w/� 21.RENIARKS
County Parcel Identification No.(PIN)
51).Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
(ifweel�llljl field,one Iat/long is
sufficient) (� 22.Cerli(Icat 1:
6:Is(are)the well(s): ®Pernlaneut of ❑Temporary Signature ofCenified Well Contractor Dole
By signing this faun,1 hereby cerl fy that the n•ell(s)-as(were)camstructed in accordance with
7.Is this a repair to an existing well: ❑Yes or inN0 ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Comtructioo Standards and that a copy
Ift his is a repair,fill one known well construction Information and explain lute nature ofthe ofthls record has been provided to the well owner.
repair under 821 remarks section at-oil tire back of this forvn.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 9T 24.SUBrvUTTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft.)
For multiple wells list all depths ifdy7erent(example-3@200'and 1@1001 Submit this GW-1 within 30 clays ofivell completion per the following:
10.Slake wales•level below top ofcasing: (ft.) 24a. For All Wells: Original font to Division of Water Resources (DWR),
I/barer level is above casing,rise"+" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Inlection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-I Lou
Geothernral 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 roducin over 100.000 GPD: Copy to DWR,CCPCUA
13a.Yield(gprn) �J Method of test: BIOW Permit Program,IN MSC,Raleigh,NC 27699-1611
131) HTH.Disinfection type: Amount: 1 lb.
i
Form GW-I North Carolina Department ofEnviroamentai Quality-Division of Water Resources' Revised 6-6-2018