GW1-2022-03559_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
p 14.WA ' ONES
FROM "TO DESCRHTION
Well Contractor Name '� ft.� ' O ft.
3441 A /
rt. rc.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased4ells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft. I by ft. i ,in. Jim 5wldit+ce
Company Name
�0 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: VV FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Ire//construction permits(i.e.UIC,County,State, Variance,etc.) R. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER i I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public I H. O ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑1n'i ation ❑Wells>100,000 GPD FROM TO ATERIAL; EMPLACEMENT 51ETHOD&AMOUNT
Non-Water Supply Well: ft. 20 ft. V
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLA LENT 51ETHOD
❑Aquifer Test ❑StormwaterDrainage ft. JPO ft. ,jej
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothennai(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hnrduess soillrock type,"n size etc.
ft. ft. (Yale
4.Date Well(s)Completed: Well1D# ft. ✓ ft.
5a.We Location: ft. 3 ft. .4A/7_=
S � 60^5f l✓e flan ft. ft.
ft. ro r•a l ?;�Facility/Owner Name Facility ID#(if applicable) ft.
SYss IV.5 '3a 1 S &VC&,ft ft. ft.
Physical Address,City,and Zip ft. ft.
MAR 2 2 ME
W 21.REMARKS
r r l
Comity Parcel Identification No.(PIN) r -
5b.Latitude and longitude in degrees/minutes/secouds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certiftcat
�5 •101019-, N CA 525 LW l '/ Z 7-2-
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby centyy that t/te rvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well. ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 01C1.0100 Mell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the hell owner.
repair under#21 remarks section or on the back of this form. 1
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-1 is.needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 39
I� (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 (R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
iriroter level is above casing,use"+L Information Processing Unit,1617 MI C,Raleigh,NC 27699-1617
11.Borehole diameter: v (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su 1 and O en-too Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department oft a county where installed
FOR WATER SUPPLI RILLS ONLY: 24d.For Water Wells producing o er 100,000 GPD:Copy to DWR,CCPCUA
13a.1'ield(gpm) S Method of test: Blow Permit Program,1611 MSC,Raleigh,tNC 27699-1 61 1
I
13b.Disinfection type: F ITI-I Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018