GW1-2022-08275_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use ORIy:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM ft, I� ft DESCRIPTION `
Well Contractor Name J
3441 A . ' .-`-Pl"1
R. ft.
NC Well Conlraclor Cenifncation Number 15.OUTER CASING for mull E""d welts OR LINER if n, licnblc
NW Poole Well and Pump Company FROM To j DIAh1ETElt TIItCICNESS aATERIAL
Company Name -
�� Dtf 06 I 16.INNER CASING Olt I DING cothernml closed-loo n
2.Well Construction Permit d' FROM I TO I DIAMETER THICKNESS MATERIAL
l.isr nil applic•nhle well cwtsuvcrion permits�.c.UIC,County,State,Variance,etc.) ft. ft. � in.
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3.Well Use(check well use): n. rt. Ia
Water Supply Well: FR SIC[tEE TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. n. in.
OGcolherinal(flcating/Cooling Supply) �Itesidential Water Supply(single) rt ft in,
❑Industrial/Cmnnnercial /ORcsidcntial Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000GPD FitoAl TO MATERIAL EaIPLACENIENI'AlrTIIOD&AMOUNT
Non-Wa(cl.Supply.Well; n. )J f,. CJ ,•/7f� G)f/r�'
❑Monitoring ❑Recovery fin ft. V
111jecliot Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK 1f n, licablc
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACENIENTN1ETHOD
OAquilcr Test ❑Slonnnvater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑'tracer 20.DRILLING LOG attach additionni sheets if necessary)
FItUN TO DESCRIPTION color,hardness soll/rack type, rain sin etc.
❑Geolhennnl(Ileating/Cooling Return) ❑Other(explain wider it21 Remarks) Q ft ft L?
4.Mile Well(s)Completed: -'2 Well IDN rt' ft. S GI. 11
5a.Well Location: ft, S ft.
Ali ' En
Iracilily/Owner Wine
(?UJ Facility IDN(ifo(ppli�c/a�bllet) AIJ/� ft• ft.
3S � ft.
r QZ?
Physical Address.City,and Zip
rt. fl.
I fA-S f / 21.REMARKS t
County v Parcel Identification No.(PIN)
5b.Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Int/long is sufficient) /� h I A 22.Cerli Rat e
�5.QV� t N 1V. V�I�[�S W 7- ��- I
6:Is(are)the nvell(s): 01'ernnanent or ❑Tenipornry SignatureorCenifted Well Contractor Date
Bp signing this farm,1 hereby cer-j'that the wel/(r)urns(were)crnrsiructed in accordance wilt
7.Is this a repair to:in existing well: OYes or "UNo 15A NCAC 02C.0100 or 154 NCAC 01C.0100 llell Constntction Standards and that a Copp
If this is a repair,fill out known wcl1 construction it forntatinn and explain the torture of the of this record has been provided to the,roll omaer.
repair under 1111 remarks.section at-on the back of this form.
23.Site diagram or additional nvell details:
3.For Gcoprobe/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 or wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 1a / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a Submit this GW-1 within 30 daysornven completion per the following:
For authiple trells list all depths tfd jcraw(example-3Q200'and 1 n 100')
10.Slake water level below top of casing: (ft.) 24n. For All Wells: Original form to Division of Water Resources (DWIt),
1/),vier/erel is above casing,tae'.�.•, Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (iu.) 24b.For Injection 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 O en.Loo GcolbernlaI Return Wells:Copy to the
(i.e.nuger,rotary,cable,direct puslt,etc.) county environmental health department or the county w icre Installed
FOR WATER SUPPL�jY WELLS ONLY: 24d.For Water Wells roducin,over 100 000 GI'D: Copy to DWR,CCPCUA
13n.Yield(gpnn) Method of(est.. Blow Permit Program,1611 MSC,Raleig i,NC 27699
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13b.Disinfection type: HTH Amouni: 1 Ib.
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Form G%V-I Nonh Carolina Deparhncut of Environmental Qunlity-Division or Wntcr Resources Revised 6.6.2018
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