GW1-2022-03555_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 fr. 10 5 fr. _rl
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for malt;-cased wells OR LINER if a licable
NW Poole Well and Pump Company FR011I TO DIA11fETER THICKNESS MATERIAL
fL m
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:JT w- r�ol(�n I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) 'fi- ft• ft. in. i
3.Well Use(check well use): ft. ft. io. p
17.
Water Supply Well: FROM ft.
TO DIAMETER SLOT SIZE TIirCIQVESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. ;a
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
NoD-Water Supply Well: V ft. � ft. G U f
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I 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)
FROM TO DESCRIPTION color,hardness soul— min size etc.
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks 0 IL
ft. t
4.Date Well(s)Completed: "1 I Z Well ID# ft. ft. C��
j�
Sa.Well
�Location:
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It-
ft-
7
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Facility/Owner Name Facility IDff(if applicable) ft. ft.
goo m;`��� �� �ll� /v`r^t �/UC ft rL *4
Physical Address,City,and Zip �' 7SZ q ft. ft. -
t��f, 21;REMARKS -
County 11 t Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one lat/long is sufficient) `� f �o 22.CertifiCat' ° j' t " 1 I`
6.Is(are)the well(s): ®Permanent or ❑Temporary signature o£Certified Well Contractor ` Date
By signing this forin,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200[Yell Construction Standards and that a copy
If tlds is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
r C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f J (fL)
Tor inultiple wells list all depths iit dii ferent(example-3(2000'annd 2�100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z 0 (ft-) 24s. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"/+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: J� (1n,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 2769t9-1636
12.Well construction method: t
24c.For Water SUDDIV 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 m ZU Method of test: Blow Pe Program,1611 MSC,Raleigh,NC 27699-161 I
' (gP )
13b.Disinfection type: HTH Amount: 1 lb.
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Forrn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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