GW1-2022-03579_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14,wATERZONES
Well Contractor Name ROM TO I DESCRwrioN
3441 A tf 0 tf a ! 6
tr. tL i
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TOtl DIAMETER THICKNESS MATERIAL
4W 6hJ_V
Company Name es n• O- ft. im .
16.INNER CASING OR TUBING fizedthernial clased4orml
2.Well Construction Permit th FROM TO DIAMETER THICKNESS 5ATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• tL in.
❑Geothermal(Heating/Cooling Supply) JXResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q IL aO ft.
a -,Som Rm A
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if ri livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemral(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color hardness saillrock a rain size etc.
9 0 ft. � ft.
4.Date Well(s)Completed: / Well ID# tt. -CAAQ' GLA
5a.Well Location: ft. ft• /S
9AII& ft. ft.
Facility/Ownerfiame Facility ID#(ifappficable) ft. ft.
S M FC)IeZ� 14A 2M 1 S 9 b.��y� ft. ft.
Physical Address,City,and Zip S I/V G . 'Hope a�a ft. ft.
fti✓ r,�/ •"'r v 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: MUS001
(ifwell field,one lat/longis sufficient) 22.Certifica
3 '
U1. 019 LA`f N - /U. 1(01�� W A 0 o?0.1*1.
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify Thai the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0No 15A NCAC 02C.0100 or 15A NCAC 02C!0200 Nell Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the well owner.
repair under#21 remarks section or on rite back of dais form.
23.Site diagram or additional well details:
3.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 ^^ r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2'p e J (It)
For multiple wells list all depths ifdierern(example-3(�00'and2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.)
24a. 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: (in.) 24b.For Injection 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 Droducine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m Blow Permit Program,1611 MSC,Raleigh;NC 27699-161 I
(gP ) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Fonn W-1 G North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018