GW1-2022-07748_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD(G W-1) For Internal Use only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Conlmclor Name FROM TO DESCRIPTION `
3441 A 37 ft. ft. �G
NC Well Contractor Certification Numbers-n.
15.OUTER CASING for mull-ensed wells OIL LINER if n r licnblc
NW Poole Well and Pump Company rnont TO DIAM1IL•TEa TIIICKNEsS NI ERIAL
Company Name
t( n. rr. In. ej CG 1 S Mel
3 / / 16.INNER CASING Olt TUBING eotheminl closed-loon)
Well2. ell Construction Permit d: 7(7/,�(p 3 FROM TO DIAMETEit I TIUCKNL•SS MATERIAL
List all applicohle well construction pennlrs(i.e.UIC,Count),.State,Irarionce,etc.) h. It. in.
3.Well Use(cheep well use): rt, ft. in.
Wafer Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL "
❑Agricultural ❑M ' ipal/Public ft. n. In.
❑Gcothernhal(I Icating/Cooling Supply) lesldential Water Supply(single) rt. in.
❑Industrial/Commercial 01kcsidcntial Water Supply(shared) 18.CROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL Ea1PLACEMENTMETnOD&AMOUNT
Non-Water Supply Well; /5 ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ff.
❑Aquifer Recharge ❑Groundwater Remediation
❑At uifer Storage and Recovery ❑Salinil Barrier 19.SAND/GRAVEL PACK if n l licnblc
1 g ry y FROM TO MATERIAL I E51PWCEMENTMETHOD
❑Aquilcr'I'csl ❑StormwaterDrainage ft. ft,
Cll?xperimenlai Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑lYaeer 20.DRILLING LOG oltach nddltional sheets if necessary)
FROM TO DESCRII"PION color,hardness sailtrock type, ruin site,etc.
❑Geothcnnal(I leating/Cooling Return) ❑Other(explain under N21 Remarks)
a ft. a fit. (o
4.Dalc Well(s)Compleletl: T 1Z Well 1D11 fit. 97 ell-
5a.Well Location:
R, ct-f fL -�
ft. ft.
facility/Owner Namc Facility IDN(ifnpplicable) ft. fit. 'Z 9,Y
t 2d z � ft. rt.l �f'GPr ns (w, n �
Physical Address.City,and Zip ft. ft. =
21.REMARKS r
�i r�ar11 c t I n,
Conroy Parcel Identification No.(PIN) Q/80G +
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(il'wcli field,one lat/long is sufficient) 22.Certilieat' +t:
35.�Z7�3° N 7�.�iD��Z° W
-�� ?- 22-2 Z.
6:Is(are)the well(s): INflermmnenl or ❑Temporary signature orCenificd Well Contractor ` Dale
BEsigning this form,l hereby certify that the well(t)was(were)constructed in accordance with
7.Is this it repair to:In existing well: 01'es or MNo 19A NCIC 02C.0100 or ISA NCAC 02C.0100 Ilell Constriction Standards and that a cop),
if/bi.s is a repair,fill oat known well carsirticiioit iii rtaation and explain the nature of the of this record hap been prowled to the well pu ner.
repair under 1121 remarks section or on ilia back of this form.
23.Site diagram or Rddilioual 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 I GW-I 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: Lt (ft.) Submit this GW-I within 30 days of well completion per the following:
Far nnthiple yells list all depths ifili&rent(example-3@200'a'^ti�d 1 rt l00')
10.Static water level below top of casing: (ft) 24n. For All Wells: Original font to Division of Water Resources (DWR),
11'11'mcr level is abave casing,use"+" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If.Borehole diameter: co (ill.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.11'cll conry,cable, method: 24c.For Water Supply and Open-Loop Geothermal Return'IV
Copy to the
(.e.m+ger,paltry,cubic,direct push,eta) county enviromnental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wclis roducin over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpnu) Method of test Blow Peanut Program,IGl I MSC,Ra eigh,NC 27699-161 l
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Deparnnenl of Environmental Quality-Division or Walcr Resources Revised 6-6-2018