GW1-2022-03486_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A log ft. 1e; ft• IT n.r
NC Well Contractor Certification Number 170 ft. "S ft xi
15..OUTER CASING for multi-cased;rve0s OR LINER if a Itcable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS atA1•ER1AL
Company Name 11
. 77 ft. la. --
16.INNER CASING.OR TUBING eothermat clo3ed-loovi
2.Well Construction Permit H: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits 0.e.U1C,County,Stare,variance,eta) ft• ft. In.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 11 SCREEN:
FROM . TO DIAMETER SLOTStZE I THICKNESS I aATERIAL
❑Agricultural )dMunicipal/Public ft. ft. In,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. In.
❑hndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-1Yater Supply Well: tD ft. 7, ft. N4 D
❑Monitoring ❑Recovery M ft.
Injection Well:
tt. ft. •
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicableFROM TO MATERIAL EaiPLACEDIENT a1ETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness soRtmek type,gran sire eta.❑Other(explain under#21 Remarks O ft. *I-
4.Date Well(s)Completed: Z (1 2�Well IDg ft. R. A&,b tag:?
5a.Well Location: �_ tt. S it. Fr ___ L
ft. Yt.
Facility/Owner Natne Facility ID#(if applicable) ft %
l91 Vibk 1J-� MAR 2(ZJtX7-dry C o,•tvv�w•�lll l�lef�N /wT a�� ft it. _
Physical Address,City,and Zip ft. ft. (`',r r`• i
FR ►k��N .,21,REMARES.
County Parcel Identification No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 21.CertifiCa
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCettified Well Contractor - Date
By signing this form,/hereby certify that;the svell(s)ivas()Pere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200,Well Construction Standards and that a copy
If this is a repair,fill out,brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair corder#21 rernarks section or air 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 info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:._ f V� n,
For multiple wells list all depths ifelferent(example-3@200'and 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:_ (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!tn•arer•level is above casing,use^+"/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b.For Injection Wells:Copy to'DWR,Undergrbund Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county. envnrotunental heal 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) 30 Method of lest: Biota Permit Program,1611 MSC,Raleigh,NC 27699-16l l
13b.Disinfection type: HTH . Amount: 1 lb.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018