GW1-2022-07953_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM I TO I DESCRIPTION '
Well ContractorNamc Z-�a rt. Z,7S rt. ?.j
3441 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased 1'vells OR LINER if am slicable
NW Poole Well and Pump Company FROM TO DIAAtETEII THICKNESS aATERIAL
Company Name
D Z 22 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit ft: �"" - O 1p 1� FROM To DIAMETER THICKNESS MATERIAL
List all applicable well constractiotr perauits(i.e.U1C,Coumy,State,Variance,etc.) ft. ft. ill.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. ft. In.
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑i1Tl ation ❑Wells>100000GPD FROAI I TO MATERIAL EMPLACEMENT DIETIIOD.&AMOUNT
Noll-Water Supply Well: D ft. ft. C U✓ ` h
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENTME'r110D
❑Aquifer Test ❑Stonmvater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG atlacb additional sheets if necessa
FROA1 TO DESCRIPTION(color,hardness soiVrock type, min size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under H21 Remarks)
O ft. 7 'Sn,
4.Date Well(s)Completed: s ( ZZ- Well IDN 2 tt. S ft. G f'I4 K
ft. yS ft. (Z
5a.Well Location: � a
racily/Owner Wine Facility fD/i(if applicable) ft. ft.
I� 1313(0 (�M-'-�P ttv� w��C �f rt. ft. P.0 G `I. T3 Z 0 ZZ
physical Address,City,and Zip ft. ft. -- a ipA -���^p. InU
INIf�� IgZ�9�p 5-It� 21.REn4ARRrKS
County Parcel Identification No.(PIN) ! At"'� � 6r
5b.Lntitude anti longilude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.CCrlifiCal'
Ill.p1,�_N ��.5� ��Q�J W �� S �� 22
c
(i.Is(are)(lie well(s): ®Perntnnent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby ceritfy that the well(s)it-as(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or "❑No 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
1%lhis is a repair,fill out known well construction h jornatiou and explain the nature of the of this record has been provided to the tie//ou-ner.
repair under 811 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
S.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
constniction,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:
24.SUBA'IITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 Lis (ft.) Submit this GW-1 within 30 days of well completion per the following:
Fop-nmhiple wells list all depths ffdiflir•ent(example-3 tt 200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below lop of casing: zo (ft.) Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
1%u•om•level is above casting,use"//+"if
i 1.Borehole diameter: b (in.) 24b.For IDieetion Wells:Copy to DWR,Underground Injection Control(fUC)
Rotary Program,1636 MSC,Raleigh,NC!27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wcl1s roducin over 100 000 GPD: Copy to DWR,CCPCUA
BIOW Permit Program,1V I MSC,R.erg n,NC 27699-1611
13a.Yield(gpm) w Method of lest:
HTH 1 lb.
13b.Disinfection type: Amount: I
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018
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