GW1-2021-07184_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
44.':RATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441A
IK /V ft. 0� ft.
80 f'. ft.
NC Well Contractor Certification Number 4 As
',15.,'.OVTER CASING(fo'r,Ttd_e1§)O�"applicable)L -4
N.W. Poole Well & Pump Co. FROM TO D T I MATERIAL
C ft. ft. in.
Company Name "W
A6.INNER CASING OR TUBING(06thermal dosed4op):
2.Well Construction Permit FROM I ;To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural oMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
OIndustrial/Commercial OResidential Water Supply(shared) IS GROUT"
01rriRation ClWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft do It. AAWITE C
oMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge 0 Groundwater Rernediation
19.SAND/GRAVEL PACK(ifs i livable)
OAquifer Storage and Recovery 0,Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology oSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer :,20.'DRILLINGLOG(attach,additiomilsheets ifnecessary)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO - DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
0 fL ft. -rop so I.
4.Date Well(s)Completed: Well IDN ft. YRAvC
5a.Well Location:
IoSr C-ANZALM ft. ft. 01
Facility/Owner Name Facility ID#(if applicable) ft. ft. V
577 Cv00b1.Ayb ocH, Rb ft. ft.
44 0
Physical Address,City,and Zip ft. ft.
C RAN ALLC
County? Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
%.Q) PJ(D—N-75.�')65]C� —W
4,
6.Is(are)the well(s):Wermanent or ElTemporary �_o f Certified Well Contractor
Dat
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or XNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the we'll owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.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: ^13 8,19 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CL—I (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths Ydfferent(example-3@200'and 2@100)
10.Static water level below top of casing: 10 24a. For All Wells: Original fort.n to Division of Water Resources (DWR),
Ifivater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: —(in.) 24b.For Injection Wells:Copy t6DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rmev
24c.For Water Su P Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) r county environmendl M9 department of the county where inst7V
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Pligoducing over 100,000 GPD:,Copy to DWR,CCPCUA
Permit Program,1611
SC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Imat'i
13b.Disinfection type: Amount: J*'Q 0?­
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018