GW1-2022-03635_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM I TO I DESCRIPTION
3441 A ft. q5 It. Zo PM
rt. rr.
NC Well Contractor Certification Number
15.OUTER CASING Ifor multi-cmcd wells OR LINER if a Iicable
NW Poole Well and Pump Company FROM TO DIAMETER THICKN/E/SS MATERIAL
�.-I ft. 7 T tt. !in. ,l it
Company Name
/_W_Q 6 79 75 _202l 16:INNER CASING OR TUBING eolhermal closed-loo
2.Well Construction Permit#: Lr FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• rL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public g• tt• W.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. w ft. �>r '(/ v
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft fr.
❑Aquifer Recharge ❑Groundwater Remediation
EDRILLING
RAVEL PACK if a Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer LOG attach additional'sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) TO DESCRIPTION color,hardness soil/rock a rein sin,etc.
4.Date Well(s)Completed: —1 2 Z Well ID# ft- '7 3 ft. (f
5a.Well Location: �[ 73 f t S ft.
`secc rU/h Dome`s ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ell? HOPltiA) IC40o C+ Zcb,)10n .1tl(_ a7597 ft. ft
Physical Address,City,and Zip ft. ft.
W 4 161 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one
]at/long is sufficient) 22.Certifreat'
✓J ,o
. Cl I `f OCR N '— i� 21 W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the iwell(s)was(were)constructed in accordance with
7.Is this a I•epair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.0100 If'ell 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 well owner.
repair under#11 remarks section or on the back ofthis 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths irdiferent(example-3@200'and 2@/00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z O ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaler level is above casing,use"+"// ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: b (ln,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.anger construction method:(i.e.auger,rotary,cable,direct push etc.) 24c.For Water SuRply and O en-Loo turn Geothermal Re Wells:Copy to the
county environmental healt department of the county where Install
FOR WATER SUPPLY WELLS ONLY:
7 24d.For Water Wells Droduceue over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gym) 7 Method of test: BLOW PenrlH Program, 1611 MSC,Raleigh,NC 17699-16l I
13b.Disinfection type: HTH Amount: 1 lb.
Poles GW-I North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2018
I