GW1-2022-03484_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM PTO DESCRIPTION
Well Contractor Name
/'a a.
3441 A /1 rt.
11iLt1 ft. I sgbs, ft. �a
NC Well Contractor Certification Nmnber M.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO IA DMETER THICKNEESS MATERIAL
ft
Company Name 0
�� 16. ER CASING OR TUBING(geothermal closed-loop)
�2.Well Construction Permit# S-G FROM TO 11 DUMETER THICKNESS MATERIAL 1
List all applicable well construction permits(i.e.UIC,Cot,iry,Slate,[Parlance,etc.) it. ft. �
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
PP Y FROM' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public et. ft. in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr.' ft. in
Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ao ft. �W
❑Monitoring ❑Recovery ft. ft.
Lljection Well: ft. tt.
❑Aquifer Recharge ❑Groundwater Remediatiom
19.SAND/GRAVEL PACK if applicable)
❑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 attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soillrockt a rein sinsetc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks O ft a tt
0
4.Date Well(s)Completed: 'AA+��-�� Well ID# tt. ft. S {
5a.Well Location: it. 0� ft.
RXAM ClrftrsA/77i ft. M
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/an8o R a RD
Physical Address,
City,and Zip ft. ft. (" 0 1
21:REMARKS
1.
t^'7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell filelldd�,�one ll�a/tioonn�g is sufficient) y 22.CertiticaC
�W• V O • v • N I�,all��� ! �mry^�ri�t5.f`t.., 'l_, .li.F�.-
W n / I\II
6.Is(are)'the well(s): Permanent or ❑Temporary S§gnature of Certified Well Contractor Date
By signing this form,I hereby certify that fire wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )fNo 15A NCAC 02C.0100 or 15A NCAC 02C'.0100 Mell Construction Standards and that a copy
If this is a repair,fill out known well construction it formation and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
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 htfo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 903
Submit this GW-1 within 30 days of well completion per the following:
For nn lliple wells list all depths ifdierent(example-3 a200'and 2@100')
Q ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground hnection Control(IUC)
Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
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 WE LS 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 27699-1 6 1 1
HTH ' 1 lb.
13b.Disinfection type: Amount:
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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