GW1-2022-03533_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: --
L Well Contractor Information:
Landon Phillips it WATERZONPS
Well Contractor Namc FROM TO L DESCRIP-TION
3441 A fY Alf, i P/r,
3/o ft 2 c ft
NC Well Contractor Certification Nuuebcr 15.OUTER CASING far multi-eased wells OR LINER Cif a Me
NW Poole Well and Pump Company FROM TO DrwMETER THICKNESS MATBR4U --
fL fi4 ia.
Company Name
16.INNER CASING OR TUBING eotherma[closed-l000l
2.Well Construction Permit TU I DIAMETER I TH1CKNM I MATERIAL
List all applicoble weld construction permits(i,e.ZI!C,Cvwny,Siate,Yariance,etc.) 4 f- 'n - J e
3.Well Use(cbeck well use): ft ft in, v
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOP SIZE THICKNESS MATZRLkL
OAgricultural C]Municipal/Public a, g, rd
❑Geothermal(Heating/Cooling Supply) &Aftidential Water Supply(single)
ft.
❑Industrial/Commerciai ❑Residential Water Supply(shared) I&GROUT
Olrrj ation O Wells>100,000 GPD FKQN1 TO TERLAI EMPLACEMENT METHOD a AMOUNT
Nou-NVater Supply Well: f/ R. w fti 4 lgyU
❑Monitoring ❑Recove:ry fL ft
Injection Well:
ft &
OAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a livable _
OAquifer Storage and Recovery OSalrnity Barrier FROM I TO :MATERIAL _ ENIFLACE.Ni NT NEETHOD
❑Aquifer Test OStormwater Drainage k•
❑Experimental Technology OSubsidence Control ft I ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal (Heating/Cooling Return OOtha(explain under#2I Remarks FROM TO I DESCRIPTION color,hardness,saWrock etc
/ ft ft P
4.Date Well(s)Completed: -! -2 weRID# ft IL
C
ft n
Sa.Well Location: ft.
M / ft
_
&ff &Idc�/:�t fL —
Facility/Owner Name Facility[DO
(if applicable) t.
icable) ft. f
2 L30 e r►r,,& t L.. Fr4,A YJ t nAp^Av c aC 7SZS ft ft —
Physical Address,City,and zip ft. ft.
[YrG n U e 21.REMARxs
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/mAnutesiseconds or decimal degrees:
(if wellfield,one lat/long is sufficient) 22.Certi6ca
6.Is(are)the well(s)' ®Permanent or OTemporary Signature ofCortified Well Contractor •e uate Z
By signing this form,I hereby certify that the wells)evas(were)consimcfed in accordmrce with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Cmistntctim Siamlardv and drat a copy
Ifthis is a repair,fill out krrmvit well constivetion information and explain the nature of the of this record has been provided to the well owner.
repair under 821 remarks section or on the back of this form.
23.Site diagram or additional well details:
&For Geoprobe/UPT 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 f necessary.
drilled: 1
[� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L -+ (�) Submit this GW-1 within 30 days of well con tion r the follow'For multiple wells list all depths rf driJerent(example-3 a 00'aed 1Q100) }B p1A per m$:
10.Static water level below top of casing: C D (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfivater level is above casing,ase'+'• Information Processing Unit,1617 MSC,Raleigh,NC 276 99-1 6 1 7
11.Borehole diameter: (;A) 24b.For Injection We Copy to DWR,Underground Injection Control(1UC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply clad O u-Lon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where costa e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
13a Yield m Method of test: Blow Permit Program,161 l MSC,Raleigh NC 9- 6l 1
(gP )
13b.Disinfection HTH 1 lb.
type: Amount-
Fount GW-1 North Carolina Department ofFavironmental Quality-Division of Water Resources Revised 6-6-2019