GW1-2022-07841_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. l6� ft. '
3441 A �0 ft. y$S fL t 6
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased ells OR LINER if a livable
NW Poole Well and Pump Company FROai TO DIAMETER THICCKNESS Il.ATERIAfL/
- S ft. �S ft. / in. Ate ALP
Company Name •7 6 .r
16.INNER CASING OR TUBING 'eothermal closed-loop)_
2.Well Construction Permit#: Q TTo� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. rn.
3.Well Use(check well use): ft. ft. in.
17.
tiYAteY Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS NSATE[iIAL
❑Agricultural ❑Municipal/Public ft. ft. is
❑Geothermal(Heating/Cooling Supply) )tesidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑.Irfi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. o ft. �v�w—if
-
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND1G1iAVEL PACK(ifapplicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG launch additional sheets if necessa
❑Geothermal(Heating/Cooling Return s❑Other(explain under#21 Remark FROM TO DFst RIPTION color hardness aoiUrock e, ruin site,etc.)
ft. d ff.
4.Date Well(s)Completed: V—C* Well ID# ft. all ft' /tIN.
ft. ft.
na.Well Locations;
tI17IIIL I dw��j
K /'He L�1e D ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2S`� HW%l -701 c Fo" OAKS ft. ft.
PliysiiccalLLAd-dress,City,and Zip ft. ft.
C107tN STo A.) 21.REMARKS t
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifca
35 . 3ggq5 N _79- 3(0132W :
S sbo��
6.Is(are)thewell(s): ®Permanent or ❑Temporary SignamreofCertified Well Contractor ` Date
By signing Uris form,I hereby certify that the wel/(s MWe e r 1pr�in� with
7.Is this a repair to an existing well: ❑Yes or LINO /SA NCAC 01C.0100 or/SA NCAC 02C.0200 l7 °h: �r t�an�al!(s gt d r copy
!('this is a repair,fill out knoirn we/l construction information and explain the nature of the of this record has been provided to the mell owner.
repair under 921 remarks section at,on the back ofthis form. 9 202_
23.Site diagram or additional well details: AUG �, .� V�
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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may .I t &,�lipggSa%"r ary
drilled: t 24.SUBMITTAL INSTRUCTIONS DwaGOG
9.Total well depth below land surface: 190 3'S (R') Submit this GW-1 within 30 days of well completion per the following:
For nmdtiple wells list all depths ifdiflerent(example-3@200'and 2@100')
^ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casiug: e/y (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1/hater level is above casing,use"+" / '
H.Borehole diameter: 24b.For Injection Wells:Copy to DWI;Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
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 producingiover 100,000 GPD:Copy to DWR,CCPCUA
/�1^ Method of test: glow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) SO
13b.Disinfection type: HTH Amount: 1 lb. I
i
Form GW-l North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018