GW1-2022-08278_Well Construction - GW1_20220822

WELL CONSTRUCTION RE,CORI)(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONGS
FROM TO DFSCRIP,TION
Well Contractor Name
3441 A 17 rf l�U R• f G _y'L11
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfl-cnseJ wells ORIN LER if n r licnhlc
NW Poole Well and Pump Company FROM T� DIAII. TUt TIIICICrN E`SS MATERIAL
,.L- ft, U i ff. in. i f ♦ .G i U"13
Company Nawc / 1
/�
16.INNER CASING Olt TUNING eotliermill closed-loo r
2.Well Construction['craft(q: I� �- 001(t �7 ]FROM I To I DIAMETER I THICKNESS MATERIAL
list all applicahle well cosnnruction perndts(i.e.UIC,Cauntp,State,I'arimrce,etc.) rr. ft. in•
3.Well Use(checlt well use): ft. tt. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSI'LE THICKNESS
MATERIAL
OAgricullural ❑Municipal/Public ft. ❑,
❑Geothermal(I-Icaling/Cooling Supply) Residential Water Supply(single) ft• ft. In,
Olndustrial/Commercial ❑Rcsidcntial Water Supply(shared) l8.GROUT
❑Irri alion ❑Wells>100,000GPD FIIOat 1 TO MATERIAL EMPLACEMENT METHOD&ANIOUNT
Non-WalerSupply Well: ft. 'po- ft. he)��?/1 �d`✓!2
❑Monitoring ORecovery
Injection Well:
OAquifer Recharge OGroundwater Remedialion
19.SAND/GRAVEL PACK if a r lit:ablc
❑Aquifer Sloragc and Recovery OSalinity Barrier FllOtii TO MAT'EIUAL I EMPLACEatENTMETHOD
OAquilcr Tcsl ❑Slormwater Drainage ft. ft.
El Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed I-oop) ❑Tracer 20,DRILLING LOG ntfach addltionnl sheets if necessa
FROM To DESCI ITTION color,hardness soillrock types rain sin etc.
❑Geothcnnal(lleating/Cooling Return) ❑Other(explain underl121 Remarks) ft ft
lam- Z
4.llalc Well(s)Completed: Well IDIt ft. 17
5a.Well Location: r
. 5ft. fl.1%acilily/Owner Naha Facility IDO(ifapplicable) ft. ft. .,L ' '�-'S 5 y/ � lc r.� Iz .5 ff n 9 n��t V 701Zff. ft:
Physical Address,City,and Zip ft.
14`ig S / 'f� 21.REMARKS e%
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decintal degrees:
(ifwcll field,ouc hit/long is sufficient) 22.Cerlifieat is
IUD° N 7%.07115 W
6:Is(are)lire well(s): (APermnnent or ❑Temporary Signature ofCenificd Well Contractor ` Date
UV signing This Jinn,I herebl,cart f•that the well(T)u-as(were)constructed in accordance]Frith
7.Is this if repair l0 all existing well: OYes or InNo ISA NCAC 02C.0100 or ISA NCIC 02C.0200 Well Conurnction Standards units flint a cope
11'thl,is a repair,fill out known well construction information and explain the nature of the nfihis record has been provided to the is-ell owner.
repair under C11 remarks section or on the back of this form.
23.Site diagram or addi(iouai well details:
S.For Geoprobe/13,11T or Closed-Loop Geothermal Wells having the same You may use the back of(his 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depot below land surface: (fl.) Submit this GW-I within 30 days of well completion per the following:
For multiple yells list all depths ifdt6crcw(example-3@200'and 1 rr 100')
24a. For All Wells: Original form to Division of Water Resources (DWIi),
1t'hrntcr Icrcl is nbare casing,use' Slake water l vet helow lip of casing: (ft•) 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;o27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Gcolherntal Return WCIIS:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where Installed
FOIL WATER SUPPL WELLS ONLY: 24d.For Water Wells producing 0�•cr 100,000 G T Copy to DWR,CCPCUA
Blow Pennit Program,1611 MSC,Rnleigh,NC 27699-161 l
13a.Yield(gpnt) V Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
I
Forms GW-I North Carolina Department of Enviroumenlal Quality-Division oC Water Resources Revised 6.6.20111
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