GW1-2022-05521_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.NVATER ZONES
Well Contractor Name -
FROM TO DESCRIPTION
3441 A o ft ft. G t�
ft. DVS ft d
NC Well Contractor Certification Number M OUTER CASING for multi-cased w OR LINER if a licable
NW Poole Well and Pump Company FROM TO I DIAMETER PTHICKNESS MATERIAL
Company Name � , C • �
16.INNER CASING OR TUBING fizeothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,I'ariance,etc) ft ft in.
3.Well Use(check well use): tt. ft. In
Water Supply Well: 17.SCREEN.'
FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. is
❑Geothermal(Heating/Cooling Supply) )('Residential Water Supply(single) ft. tt. in
❑hldustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
011TI ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n IL
T Nf �Gt't EA
❑Monitoring ❑Recovery ft ft.
Injection Weil:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/mck a rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks O ft. A ft. Z_
4.Date Well(s)Completed: t/_ ?_XWell ID# ft' S "'
5a.Well Location: $' ft.
�eSf S o?'Z ft iL /T
Facility/Owner Name Facility lD#(if applicable) ft. ft
/3*71 FAG L f 91 btl b R ft. ft.
Physical Address,City,and Zip ay) ft. ft
JVR 21:REA7ARKS n A E 6
County Parcel Identification No.(PIN) c
OF uE:i 6-" I ON
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `'"`�O'�'`�"T`-''
(if well field,one lat/long is sufficient) 22.Certifica
35.29 gi11 N �l�v n��- w I' .J.2
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor _ Date
By signing this form,I hereby certify that rite ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0100 lVell 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#21 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: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /ps• S (ft.)
Far multiple wells list all depths ifeli ferent(example-3@100'and z@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top orcasing: PO (ft.)
B 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use +^ / ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method,
(i.e.auger, 24c.For Water Supply and Open-Loop
Geothel Return Wells:Copy to the
,rotary,cable,direct push etc.) county environmental health department of a counrma ty where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells -duciri over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ' ! Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I