GW1-2022-07959_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A .3 ft. 3 S ft. A
ft.
NC Well Contactor Certification Number 1/0 ft.
15.OUTER CASING for multi- ed wells OR LINER(ifairplicable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. . ) w 1',cJ
Company Name16
'A 16.INNER CASING OR TUBING eothermat closed-loci))
2.Well Construction Permit#: 1j LV- O7j,411-2422 FROI,i I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable,cell construction perrnils(i.e.UIC,County,State,Variance,etc.) ft. ft.
in.
3.Wei Use(citecil well use): ft. ft. in.
R'atel Supply Well: 17.FROM SCREENTO DIAMETER I SLOT SIZE THICKNESS 111ATLRIAL
❑Agricultural ❑Municipal/Public H. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)❑Lldustrial/Commercial ❑Residential Water Supply(shared) 1g, R ft. I ft. in
C
❑hri atiotl ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. U t7 Ja
❑Monitoring ❑Recovery tt. ft.
Injection Well:
tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicable
FROM TO MATERIAL EMPLACEMENThIETIIOD
❑Aquifer Test ❑Stonmvater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG atinch additional sheets if uecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soillrock e, rain sin e(c.)
ft. 0ft. )
4.Date Well(s)Completed: S"`l`ZZ Well ID# ft. e7 I ft. 4CI4, V
5a.Well Location: 265
t ft. ft p-s
I! .SKy e_s+c *eS ID
Facility/0 ter Name Facility ID#(ifapplicable)
ft. ft. a�"
�f 6 �3136 (ran 'c SA rron ko� "�Prend it. fL AIJr � -
Physical Address,City,and Zip ft. ft.
NC a 7sg 7 � � .a
21.REA7ARKS n,;,:q,<
Count)' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certiflca A:
N '3�'a��a'' W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert jy that the,rell(s)was(were)construcred in accordance,rith
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 02C10200 Well Construction Standards and that a copy
I(Uris is a repair,fill out knonrn,yell construction information and explain the nature of due ofthis record has been provided to the well owner.
repair under P21 remarks section at-on the back of this fora.
23.Site diagram or additional well details:
8.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 also attach additional pages if necessary.
drilled: 1 24.SUBA'fITTAL INSTRUCTIONS
9.Total well depth below land surface: _�05 (ft.)
Far nnr/tiple wells list all depths Id fferenl(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original font to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+f
1.1.Borehole diameter: .t7 (iD,) 24b.For Injection Wells:Copy to DWR Underground Injection Control(NC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su I and 0 en-Loo Geothermal Return Wells:Copy to the
(i.e.Huger,rotary,cable,direct push etc.) county envlroilmenta healt 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(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,[NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form G%V-t North Carolina Department of Environmental Quality-Division of Water Resources '�, Revised 6-6-2018