GW1-2022-08282_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Nrdl Conirndor Name
FROM TO DESCRIPTION
6 rt. j 7 a.
3441 A
n. a.
NC Well Contractor Certification Number
15.OUTER CASING for mull)-cased wells R O LINER if n licnblc
NW Poole Well and Pump Company FROM TO U.Afl.ETER TIIICKNLSS MATERIAL
Company Name
16.INNER CASING Olt TUBING eotl,ertnnl closed-loo n
2.\Vell Construction Permit#: rROnt TO DIAMETER THICKNESS MATERIAL
I.i.ct till applicable well construction perndrr(I.e.UIC,Caanly,State.Irariance,ere.) ft. ft. inn.
3.Well Use(check well use): H. rt. tr`
Witter Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Mon icipal/Public rt. ff.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.CROUT
❑Irrigation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT afE•THOD&A51OUNT
Noll-1Yalcr Supply Well: Q ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ff. rL
❑Aquifer Recharge ❑Groundwater Remedialion
19.SAND/GItAYEL PACK if n h licnblc
❑Aquifer Storage and Recovery ❑Salinity Barrier Motif TO MATEIUAL EMPLACEM ENT[VIET[IOD
❑AquilorTcsl ❑StormwaterDrainage R. ft.
CIExperimen(al Technology ❑Subsidence Control ft. ft.
OGeolhermal(Closed Loop) ❑•'racer 20.DRILLING LOG oltach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,sollfracklype,grnin siu tic.
❑Geothermal(Healing/Cooling Return) ❑Other(explain under#21 Remarks) Q ft. j ft. 0 a
4.Mile Well(s)Completed: !` I S. Id Weil lim ft. I• ) R.Qt
., s
n, n, �.;e L_a V ..
5a.Well Location: I O-5 „ A
--�A c Ilk ft. j r, 2 2 2022
I;acilily/Owner Name facility 1DH(ifapplicable) rt. rt.
101 AVeAUe3- S��''�� IlyPe N� f a.,c� rf �s :ftg ftwt
Physical Address.City,and Zip J ft. fl.
NAG' 21.REMARKS
County ) Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(ifwcll IiciJ,one IaUlong is sufficient) 22.Certiflcat
6:Is(are)(lie well(s): (Nilernlnmen( or ❑Temporary Signalure ofCcriftcd Well Contractor Date
l3v signing this farm,l hereby certif•that the rreN(.c)was(mere)constrnded in accordance frith
7.Is(his:I repair W an existing well: ❑Yes or "UNo ISA NCAC 01C.0100 or ISA NCAC 01C.0100 It ell Constntcrion Siondar•rlt and that a copy
lJ"tlr.,is a repair,fill out known well construction irnforuration and explain/lie nature of lire of this record has been provided to the hell omner.
repair Hauler•1121 remar•kv section or on die back of this forin.
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(his page to provide additional weil 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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OA 0 S M) Submit this GW-I within 30 days of iweli completion per the following:
For midRple malls fist all depths Iy'&&rcnl(exanrplc-3 200'and 1 r@100')
10.Sln(ic water level below lop of casing: ( ) 24n. For All Wells: Original form to Division of Water Resources (DWR),
(firaicr level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Ilmeholediameter: (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 Su 1 and O en'-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,cic.) county enviromnental ealth department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin 'over 100 000 0 1 : Copy to DWR,CCPCUA
13a.Yield(gym) Method of test:
G Blow Penn it Program,161 MSC,Rnlcigh,NC 27699-161 I
HTH 1 lb.
13b.Disinfection type: Amount:
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Form OW-I North Carolina Deportment of6n6ronmenial Quality-Division of Wnler Resource's lteviscd 6-6.2018
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