GW1-2021-02230_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14;.WATERZONES� --;-.,%,::-,'--,""; ;,�,-
A­:
Well Contractor Name FROM TO DESCRIPTION
3441 A L rt. 'T i plq\
IMO\
NC Well Contractor Certification Number c(5
...15.,.OUTER CASING(for multi-eased*elh) LINER,ffq"`licablk)z_-
N.W. Poole Well & Pump Co. FROM I TO DIAMETER THICKNESS MATERIAL!
ATERL4,L-D_ ( (11 I
Company Name ft. 2 ft- r
in. 1 . lk
NER CAST ING(66thermal closid-looiW
2.Well Construction Permit FROM TO DIAMETER I THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft.
Water Supply Well: SCREEN'-
FROM TO DIAMETER,T—SLOT SIZE I THICKNESS I MATERIAL
OAgricultural O��Muni ipal/Public ft* a0ft. I I!re I pyl,
DGeothermal(Heating/Cooling Supply) esidntial Water Supply(single) ft. ft.
01ndustrial/Commercial OResidential Water Supply(shared)
;18.,GROUT
El Irrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. f�o It- ht),k A CAI Eo-fl-
ElMonitoring oRecovery ft. ft.
Injection Well:
ft. ft.
0 Aquifer Recharge OGroundwater Remediation
'19.SAND/GRAVWNTUPAEUPA if abolkabli)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
CAquiferTest CStormwater Drainage ft• ltL/t. e
OExperimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 1k DRILLING.LOG(attach gidditioiW.'sheets-if nec6sary)
FROM TO rains' etc.)
DGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) DESCRIPTION(color,hardness,soillrock type, me,
ft. ft.
4.Date Well(s)Completed: t Well ID# ft. ft.
5a.Well Location: ft- ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. r
Zo _56rflf, ( Dr , �(ct,k)(Alu,1 IVC- DSU ft. ft. Jul-
Physical Address,City,and,Zip ft. ft. �?'Ion yloce ul
10nW1,3k=21.REMARKS,.. Zan"
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertiflcatiuA�,_,�
N S-1(o 2� w
6.Is(are)the well(s): Wrernument or ElTemporary of Certified Well C Date
signing By 17,�fo,.,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or 0 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 ofthe of this record has been provided to the well owner.
repair under 021 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yob may also attach additional pages if necessary.
drilled: I — - 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths Ydifferent(example-3@200'aW 2@1-00') (ft-) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing. 2 U_ 24a. For All Wells: Original fonn to Division of Water Resources (DWR),
(1`0 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter v (in.) 24b.For Injection Wells:Copy to IDWR,Underground Injection Control(IUC)
y
Program,1636 MSC,Raleigh,NC 27699-1636
1
12.Well construction method: CA(
24c.For Water Supply and Open-Loop Geothermal Return�Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) couniT—
environmental
health departin ent of the county where in le
ia
FOR WATER SUPPLY WELLS ONLY: I
I 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,,NC 27699-16 1 1
13b.Disinfection type: Amount: 1 L
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018