GW1-2022-06745_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRIPTION
well Contractor Name /LJ ft. ft.
3441 A 7
ft. ft
NC Well Contractor Certification Number 1S.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FRO�I TO DIAMETER THICKNESS MATERIAL
Company Name r r
16.INNER CASING OR TUBIN eothermal closed-loop)
2.Well Construction Permit#: 4�Y1u1 11 I 1`1 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,Cbrinty,State,Variance,etc.) ft. ft. 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 R, ft, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.'
Idustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATE EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft• rQ ft. ('' UIm
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRO51 TO DESCRIPTION colorrdness soutrock type, rain sin etc.)
ft ft. ft p t•L
4.Date Well(s)Completed: 1- Z Z Well 1D9 2 ft. O ft.
So.Well Location: �,�QM. Q ft. Q ft, rL^e
S Pc,�Y �UtifU►"K�� ft. ft.
61
Facility/Owner Name Facility ID#(ifopplicable) ft. ft.
7/1I V r+&rn A. S jl� it &ze%2 r - r 2c� ft. ft.
Physical Address,City,and ZipCr"moor /(/L Ot 7s 2 ft. ft. ,�„A q P lt,,,
ns li
`''
h k 21.REMARKS n
JUN 0 3 2022
ounty Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) r t c' 22.Certirica '
3� 30Q.a. N h v3'� ' `1� a 't W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the svell(s)Bras(here)constructed in accordance rrith
7.Is this a repair to all existing well: ❑Yes or IRJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cop),
/(this is a repair,fill out known the/l construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under-#21 rentarks section or-on tire back of this 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-I is heeded. 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: S (ft.) Submit thus GW-1 within 30 days of well completion per the following:
For nm/tiple wells list all depths ifdierent(example-3@200'and 2@100') .
Z y� k 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below'top of casing: (J ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If Crater level is above casing,use"+'
11.Borehole diameter- (in,) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) I/l2 Method of test: Blow Permit Program,1611 MSC,Raleig,r,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
V
Form GW-1 North Carolina Department of Eavironmental Quality-Division of Water Resources, Revised 6-6-2018