GW1-2022-07749_Well Construction - GW1_20220819

WELL CONSTRUCTION RE'CORD(GW-1) For Internal Use ODIy:
I.Well Contractor Information:
t
Landon Phillips I4,WATER ZONES
FROM TO DFSCRIPTION
N�cll Contrnclor Nnnic a3o ft. ]� 9 /�
3441 A .7 ✓
NC Well Conlraclor Certification Number 15.OUTER CASING for muhl-cnseU wdis OR LINER if n/ licn6lc
NW Poole Well and Pump Company FROM To DIAMETER TIfICKNESS MATERIAL
fh ft. In,
Company Nanwb
LL{/+�+�+�sssLLL///� 16.INNER CASING OR TUBING eolhernmi closed-loo:
Well2. ell Construction Permit#• FROM TO DIAnIE'fER T'IIICICNLSS MATERIAL
List all applicable well consliwelion permifs(i.e.U1C,Camnyt Stale,Irariance,etc.) ft. S If. / i�u �� j
3.Well Use(check well use): A. ✓ ff. ` is
Willer Supply Well: 17.SCREEN
FROM TO DIAMLTES, SLOTSIZE THICKNESS AIM ERIAL
❑Agricultural ❑Municipal/Public rt. ft. In.
❑Geothermal(I-lcaling/Cooling Supply) AIlesidential Water Supply(single) f. ft. in.
❑Industrial/Commercial '❑ILcsidcntial Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACE41ENTMET1101)&AMOUNT
Nou-Wnlcr Supply Well: O ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ff. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a 1 licnblc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EaIPLACEaIENTNIET1101)
❑Aquil'cr'I'cst ❑Slonnwater Drainage ft. I ft,
CIL•xperimenlal7'echnology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑)'racer 20.DRILLING LOG nitach additionnl sheets if necessn
❑Geothermal(I leating/Cooliag ltclum) ❑Other(explain under#21 Rem FRoAl T DESCRIFfION color,bnrdness sollfrock type, min siu etc.arks) ff. ft. e�j fL
4.Date Well(s)Completed: as as Well ill#
Sa.1Vdl Locution:
(`r- 4✓1 SeS S O N S If. ft.
Facility/Owner Nninc /JFacility ID1(if applicable) It. ft, cF
Physi nl Address.City,and Zip ft, ft. ] _
—Fct ^y n 21.REMARKS , f .`Y `Mrs �
t+�1/' U
County Parcel Identification No.(PIN)
Sb.Latitude find longitude in rlegrccs/minutes/seconds or decimal degrees:
(il'wcll field,one Int/long is sufficient) 2;�R::
501%t9 N 1S, lq0 W
2? 2 'z
6:Is(arc)the wcll(s): DtlPernumlcut or ❑Temporary Signature ofCcoified Well Contractor Date
livsigning dtifii-in,/hereby,cerll,that the well(v)was(were)constructed in accordance with
7.Is this a repair to in existing well: ❑Yes or "UNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 IPc/l Cmirinictiolh Standards and that a coP),
!J'lhis is a repair,fill out Inrou n u cl1 carsn ucliat infornrotlan atd explain!hc nano a ojllhe ajlhis record has been prorlrlerl to the u'e/f owner.
repair under 1111 reurarkr section or oil the back ojthis forhn. 23.Site diagram or additional well details'
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die 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: i 12 4 24.SUBMITTAL INSTRUCTIONS
9.TMill well depth below land surface: (f(') Submit this GW-I within 30 days of hvell completion per(lie following-
liar endliple walls list all depths Ifd6qcrctu(example-3 r@200'anndjd��20100')
10.Static water level below lop of casing: 2V (ft) 24R. For All Wells: Original form to Division of Water Resources (DWR),
l/lrarcrlcre/.&above casing,nse'•�•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
11.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 O en-Lo op Geothermal Return Wells:Copy to the
(i.e.nugm,rotary,cable,direct push,cic.) county environ mental 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(gpni) Method of test:
Blow Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b,Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Deprlmenl of Environmental Quality-Division of Wntcr Resources . Revised 6.6-2018
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