GW1-2022-06928_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRH'TION
Nell Contractor Name ft• a G M
3441A /O
R. f1
NC Well Contractor Certification Number 15.OUTER CASING for mtild-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
,S ft• �lo.s ft. ia. JAT �Aw
Company Name 16.INNER CASING OR TUBING eothermal closed-loop) 4
2.Well Construction Permit#., FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,(Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
\\'stir Supply Well: 11.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. In.i
❑Geotliennal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft. in
❑Industrial/Cominercial ❑Residential Water Supply(shared) 18.GROUT
01rri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACE51ENT METHOD&AMOUNT
Nou-Water Supply Well: G ft. 90 tL AFvTc,'1TtF i Dam0fib
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I Ertl PLACEM ENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geotliennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geotliennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks rFROMTO DESCAiPTION color hardness solVrock a ra n size,etc.aft.4.DateWell(s)Completed: 3-3/w�a Well ID# 8gft.5a.Well Location: S'°�$ ft• G ��S S/4N%/PA/cE�0 fL
Facility/Owner Name Facility ID#(ifapphcable) ft. ft.
/c7 LOA0h% foty% 'M60p4aN /VC ft. ft.
Physical Address,City,and Zip d/J 7 7 ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) ritir' 'i Ar I f r! aL' •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifies .
3 J. N --_7 �(o��Ql W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that One icell(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 01C.0100 or ISA NCAC 01C.0100 ii'ell Construction Standards and that a cog),
/(this is a repair,fill out known well construction information and explain the nature of Ore of this record has been provided to One ivell owner.
repair under#21 remarks section or on life back of this form.
23.Site diagram or additional well details:
3.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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 S (R') Submit this GW-1 within 30 days of well completion per the following:
For nudtiple irells list all depths ifdierent(example-3@200'and 1@100)
70.Static water level below top of casing: 3(1 (it) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water lire/ above casting,use'+
1.1.Borehole diameter: (in.) 24b.For Infection 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 O en-Loo 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 roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.1'ield(gpm) ♦
f� Method of test: Blow Permit Program,1611 MSC,Raleig ,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-l North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8