GW1-2022-03502_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14,* TER ZONES..
Well Contractor Name FROM TO DESCRIPTION
3441 A rt. �S rr. CsP&-L
tt. /Scs ft d NC Well Contractor Certification Number
15,OUTER CASING for multi-cued w OR LINER ifa livable
NW Poole Well and Pump Company FROM 11f
TO DIAETER THCMEESS MATERIAL
Company Name '• Y r ". [ I ft. In. I in,
v
16.INNER CASING OR TUBING eothermal closed-loan)
2.Well Construction Permit#: FROM TO I DIAMETER I THHCKNESS IMATERIAL
List all applicable well construction permits(i.e.UIC,County,,State,Variance,etc.) n. ft. in.
3.Well Use(check well use): ft. ft. In
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE I THICKNESS 11fATERIAT,
❑Agricultural ❑Municipal/Public ft. R. In.
❑Geothermal(Heating/Cooling Supply) )(Residential Water Supply(single) H. R. In.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01n'I ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water'Supply Well: 0 rt. ft' TON
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salmi Barrier 19.SAND/GRAVEL PACK ifa livable
ty FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑L-xperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20•DRIG LOG attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM LLIN TO DESCRIPTION color,hardness soi0rock a rain size etc
Q ft. it. .•V� L
a.Date Well(s)Completed: : 7_XWell ID# ft ICL se
. a ft• 'a
5a.WWell Location: ff• ,l R• D S, zriA L'
fI a S3 S o'"Z ft. ft
;�,—1
Facility/Owner Name .Facility ID#(if applicable) ft. ft -
/3q-71 EAGLE Ri ttE D R ft. ft. _
Physical Address,City,and Zip ft. fL
NR 7e_iq w`b
_zl:REi►fAItKS7� e C .
County Parcel Identification No.(PiN) c �/ Il r "'O` ttft Di6va
5b.Latitude and longitude In'-degrees/minutes/seconds or decimal degrees:
(ifsvell field,one]at/long is sufficient) 22.Cettifieat'
6.Islam)the well(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,]hereby certify that the reell(s)ivas(here)constructed in accordance unlit
7.Is this a repair to an existing well: ❑Yes or ©No ISA NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ireh'construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 rentarkr section or air the back of this farm.
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: t 1 .
/4-S' S 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
(ft.) Submit this GW-1 within 30 days of well completion per the following:
For nadriple wells list all depths tjd�erenr(exam pie-3@100'mrd 2@/00)
10.Static water level below top of casing' 90 (h) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifirorer level is above casing,use^+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I1.Borehole diameter: (1n,) 24b.For Injection Wells:Copy to DWR,Underground injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
i.e auger construction method: 24c.For Water Su 1 and O en-'Lon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental heal apartment of a county where installed
F012 WATER SUPPLY WELLS ONLY: 24d..For Water Wells roducfn over 120 000 GPD:Co to D S Copy WR CCPCUA
13a.Yield(gpm) ( Method of test: Blow Permit Program,1011 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
j
Forur G W-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018