GW1-2022-03553_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 3 k ft- G S ft• / �'n,
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased welb)OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name
l ft 9 1
b in. s
�y/ 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: �W•' C q //�/ LE/ZG FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,[variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREENTO DIAMETER I SLOTSIZE I THICKNMS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fr, in.
❑Industrial/Cominercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Ctt. .7 tt. l Or �:A,—
❑Monitoring ❑Recovery ft. it.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aqu 19.SAND/GRAVEL PACK if alivableifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. m
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soillroek a •n size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 tt• Z ft.
4.Date Well(s)Completed: _f S z Well ID# L ft. S' tt. /�„ y S�n f
5a.Well Location:
CUn 5trJG4,•J,1 ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
S S 061 Ui �(J.�r1�c.r�l,(� P(? M'IL TVf eS)Nc ft. ft. _5~ k.;
1 -
;rr
Physical Address,City,and Zip �7 �'� ft. ft.
W("k'_ 2L REMARKS
County Parcel Identification No.(PIN) F
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ii',f-L',H�e;11
4-r- N It. �le� 22.Certificat' : /
W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor " Date
By signing this form,i hereby certify that thiwell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 01C.0100 or 15A NCAC 02C.0200]fell Construction Standards and that a copy
lfthis is a repair,fill out known well construction b formation and explain the nature ofthe ofthis record has been provided to the well oivner.
repair under#21 remarks section or on the back of this 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: t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For mulliple wells list all depths tfdierent(example-3@20o and 1@I00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 (B 24a. For All Wells: Original form to,,Division of Water Resources (DWR),
l,/'rraterlevel is above casing,use'+ ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (1n,) 24b.For IDiection Wells:Copy to DWR Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.auger 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: i
f 24d.For Water a'Vells producing over 100,000 GPD: Copy to•DWR,CCPCUA
13a.Yield(gpm) 1 Method of test: BIOW Permit Program,1611 MSC,Raleigh,NC 27699-161 i
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018