GW1-2022-06748_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRHTION
3441 A a G ft. q ft. Vm
ft. fL
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased welts OR LINER if a licebee
NW Poole Well and Pump Company FROM TO DIA ETER TH[CKNESS MATERLIL
Company Name 7H
ft. pz ft. ;in. t �Ct(t�trfC:,.C-1
16.INNER CASING OR TUBING eothermal closed-10013)
2.Well Construction Permit#: FROM TO DLIMETER I THCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.) rL ft. I in.
3.Well Use(check well use): ft. ft. is
Water Supply Well: 17.FR011fREE TO D[AMIETER ' SLOTSIZE THICKNESS 51ATERIAL
❑Agricultural ❑Municipal/Public ft. ft. is
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD -FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft. ft.
0 /v JI
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MIATERLU I EMIPLACEMIENT 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)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solUrock type,grain sin etc.)
0 ft. a e. 1 a L
4.Date Well(s)Completed: "f7^Z W,ell ID# ft. T7 ft. C��
9a.a1'eli Location: ft. SdS ft' (dn.I�-
/t L_`S ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft. r,IF ¢f .
Physical Address,City,and Zip 7 C� ft. ft. '
21.REMARKS
County U Parcel identification No.(PIN)
s -
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'��''':���';i
(if well field,one]at/long is sufficient) _ _ 22.Certilica
lO l �Cv0 N 7�t5��5 S W
6.Is(are)the weil(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,/hereby cert fy that the wells)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 01C.0100 or 15A NCAC 01C,0100/Yell Construction Standards and that a copy
Il lhis is a repair,fill out knowit ivell construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back ojthis forn.
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.SUBNHTTAL INSTRUCTIONS
9.Total well depth below land surface: Sa s.For multiple wells list all depths ifdgerent(example-3(a3100'and 2(a3100� (g,) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: C�_ V (ft.)
h 24a. For All Wells: Original form to Division of Water Resources (DWR),
1(urater 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: 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.field(gp m) 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