GW1-2022-03554_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
M14.WATERZONESSWell Contractor Name DESCRIPTION
3441 A 5 ft.
ft. Wi —
NC Well Contractor Certification Number
for multi-casedwells ORLINER ifa licableNW Poole Well and Pump Company DLIMETER THICKNESSMATERIAL
Counpany Narne
ft.
16.INNER CASING OR TUBING(geothermal closed-loop)
1.W¢11 CODSfruCtlOn Permit 4: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.SAC,County,Sate,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
❑A ricultural FROM TO DIAMETER SLOT SIZE THICI9VESS MATERIAL
g ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single)
R. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
1S.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 2-6 ft.
❑Monitoring ❑Recovery ft. ft.
lujection Well:
❑A uifer Recharge ft. ft.
9 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK if a licable
�' FROM TO I MATERIAL I EMPLACEDIENT METHOD
❑Aquifer Test ❑Stormwater Drainage tt. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLWG LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness soil/mck type,grain size etc.
/ ft. ft.
4.Date Well(s)Completed: ►a z! Well IDIt a ft. ft. v
5a.Well Location: L ft. ft. °�-
P+f� J�WMC4 n ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft. ((^ r f �.^•t
9so F cle'l r C.U,J eov d` W/n.lL-Pj(:Sd . rt. ft. 9`
Physical Address,City,and Zip ^/� of 75�� ft. ft.
_21.REMARKS
County Parcel Identification No.(PIN) I1. :w,v_L•I l�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 11.Certificat'
A."40
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that thewell(s)was(were)corutructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Ifrell Construction Standards and that a copy
Ifthis is a repair,fill out latown well construction information and explain the nature ofthe ofthis record has been prarided to the well owner.
repair under 921 remarks section ot•on the back ojthis 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
Zv 24.SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: (ft.)
For multiple,yells list all depths ifdfferent(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 ofcasing: Z (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+r; Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
b i
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction cable,
method: 24c.For Water Supply and Open-Loop Geothermal Return 1i'e'is•Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county envrromnental 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.field(gpm) Method of test: BIOW Permit Program,1W I MSC,Raleigh,NC 27699-I611
13b.Disinfection type: HTH Amount: 1 lb.
IP i
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018