GW1-2022-08289_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use OBIy:
1.Well Contractor Information.
Landon Phillips 14,WATER ZONES
Well Contractor Name F FROM
f4 r S D fL DESCRIPTION
3441A s
Cis fl. W� R,
NC Well Contractor Certification Number 15.OUTER CASING for mull-Swell Is'10 L[NER if afillicahlc
NW Poole Well and Pump Company FROM TO UTAM11ETEli T...CKNESS M1IA7'ERIAL
fI. i `I a fr. tn. . (f! �
Company Nanto •,
©� ���� 16.INNER CASING 0111 UBING colhn n enai closed-loci
2.Well Construction Permit th 1,1101,11 TO DIAMETER THICKNESS I DIATERIAL
Litt all applicable well construction permits rt.e.UIC,County,Slate,Ira lance,etc.) fl. ft. in.
3.Well Use(cliccil well use): rr. rt. iry
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL "
❑Agricultural ❑Municipal/Public t fr. 2(;C.trt. L in. . cl G AIL
❑Geothermal(I-Icating/Cooling Supply) /l�Residential Water Supply(single) rt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑II•ri ation ❑Wells>100,000GPD FROM TO MATERIAL FNIPLACEDIENTDIETIIOD&AMOUNT
Non-WalerSupply Well: D ft. ft. hU�<?1 `ICI
❑Monitoring ❑Recovery ft. ft.
Injection Well: ff. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a r licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEMAL I EMPLACEDIENThIETHOD
❑AquilcrTest ❑StormwaterDrainage ft- z 0LI ft' 5 U✓
❑Lxperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑-I'racer 20.DRILLING LOG allach additional sheets if necessary)
❑Geothermal(1-leating/Cooling Kelu mar
m) ❑Other(explain under N21 Reks) FI10111 TO DESCRU"P•�ION j�
color,hardness soillruch type. rain sin etc.
�! �5'1' t
4.Dale Well(s)Cmnplelell: •-o?1`z Z We11 1llN
Sa.\Yell Location: I f4 d t Se%S (�
1'1 rn 1 i 1 r/1—^ -s:�, n I% l`2�
7
Facility/Owner Name Facility ID9(ifopplicable) ft. ft.
uOY.") {7r7c�1 v �C J�r,M /`C7�C /Z ft. ft. uCisYic�«t"1 s U
Physical Address.Cily,and Zip Id
J 7 C Z ft. ff.
v
/]/4 S-1/ 21,REMARKS t
Counly Parcel Identification No.(PIN)
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irweil field,one Iattlong is snflicient 9 22.Cerl'Iricat' A:
f�r1ZLl� N Ar ,Il W
6:ls(are)the well(s): OPermaneut or ❑Temporary Signature ofCenified Well Contractor ` Dole
I%vsigning this farm,I hereby certify that the irell(s)u•as(were)constructer)in occordmue with
7.Is this a repair loan existing well: ❑1'es or InNo ISA NCAC 01C.0100 or ISA NCAC 01C 0100!fell Constriction Standards and that a copy
If this is a rerair,f ll out known ire//construction itr/m•nration and explain the nature of die of this retard has been provided to the well owner.
repair under 1111 renmrkr section or oil the back of dais form.
23.Site diagram or additional well details:
S.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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You''-may also attach additional pages if necessary.
drilled: I24.SUBMITTAL INSTRUCTIONS
well depth below land surface: L.J�-�S (fl.
For multiple wells list all depths ifdi/fcrctu(exantplc-3 n 00'and 1 a 100') ) Submit this G1V-1 within 30 days oht•cIl completion per the following:
10.Static water level below lop of casing: (ft*) 241. For All Wells: Original form to Division of Water Resources (DWR),
(/'water level is abase casing,use"i."- information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: tilt,) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(JUC)
Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Gcothcrnial Return Wells:Copy to the
(i.e.anger,rosary,cable,direct push,etc.) county enviromnental health department of the county where installed
FOR WATER SUPPL ELLS ONLY: j
l/�\ 24d.For Water Wells producing ov�er'100,000 GI'll:Copy to DWR,CCPCUA
13n.field(gpin) Method of test: glow Pennit Program,1611 MSC,Raleigh,NC 27699-161 1
HTH 1 lb.
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Deparhnenl of riwirotunental Quality-Division or Water Resources Revised 6-6-2018