GW1-2022-03500_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 DESCRIPTIONft. /C Oft. Q �-
3441 A
ft. ft.
NC Weil Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL,
Company Name I Ct. ! ft. in. I
t ..y 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: t ,' / / FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counly,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER` SLOTSIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial Residential Water Supply(shared) 18:GROUT
❑Irri atioil ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEaIENT atETHOD&Ah10UNT
Non-Water Supply Well: 45• ft. 2,v ft. /� .t% �/ ✓r
❑Monitoring ❑Recovery ft. ft.
Injection Well:
tL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness SoiV,rocktype,grain size etc.
l ft. ` C
4.Date Well(s)Completed:( `I 2 Well ID# ft. tI_ C.
he,(
/ `j ft. It.
Sa.Well Location:
71'(— e,(d J— Vt y ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
C I�Y f�g iUL o 752 0 ft. ft. P F C
Physical Address,City,and Zip ft. ft.
�adhnVy (\ 2LREN1ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: w
(ifwee�lljjfield,onelalajttllonng is sufficient) 22.Certifrca
(.j Qo '
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Dilate
By signing this form,I hereby certify that the sve/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a cops,
If this is a repair,fill out known well construction information and explain die nature of the ofthis record has been provided to the yell owner.
repair under#21 remarks section or on the beck of this form. I
23.Site diagram or additional welldetails:
8.For Gcoprobe/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: (ft.
Far nahiple wells list all depths lfdierent(example-3@20^0''and 2@I00') ) Submit this GV1'-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ` 6 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
IJ'waler level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: �_(in.) 24b.For IDjection Wells:Copy to DWR,Underground Injection 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 WELLS ONLY:
24d.For Water Wells Droducins over 100,000 GPD:Copy to DWR,CCPCUA
BIQW Per
13a.Yield(gpm) U Metbod of test m it Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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