GW1-2022-03493_Well Construction - GW1_20220322

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 I L6rt 1 rt10 lip'll
0 rt -r rr. 20 P^
NC Well Contractor Certification Number
15.OUTER CASING for mWH-case wells OR LINER if ap, livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
.t ft ft- io. I� (�(U,YIGtt�
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.iJIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft m.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M crpal/Public k. tt. in.
❑Geothermal(Heating/Cooling Supply) PKesidential Water Supply(single) ft. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bTl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMP14CEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft ft. U
❑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 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)
❑Geothermal(Heating/Cooling Return)
TO DESCRHT) Other(explain under#21 Remarks) G ft z ft. ION color,�O hard�rness�soil/mck rain s' etc
4.Date Well(s)Completed: ' Z Well ID# ft f[.
5a.Well Location: ft. 2A,S It.
fttf It-
ft. fr.
Facility/Owner Name Facility ID#(if applicable) ft ft _
15�9 Brook- d-rt`ye yK 711 ft ft
Physical Address,City,and Zip ft. ft. 7
/fin vl°L, 21.REMARKS
County v,t '`L Parcel Identification No.(PIN) -T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) �]nu ^� _ /- 22.Cert'li
N 1!J I����L7 W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby certify that the well(s)was(were)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
If1his is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the spell 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 info
construction,only 1 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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZS_ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi,/ferent(example-3@200'and 2@100)
10.Static water level below top of casing: Z0 (ft.) 24a. For All Wells: Original form'to Division of Water Resources (DWR),
Ijwater level is above casing,use' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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 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
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13b.Disinfection type: .HTH Amount: 1 lb.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018