GW1-2022-03583_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATERZ40N,
Well Contractor Name FROM TO I DESC TION
3441A /p��� It. /$0 it• a !6
!/ O
NC Well Contractor Certification Number ft. / Q ft. O
IS.OUTER CASING for multi-cased we0s OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
rt. rt. in:
Company Name
Q Q' 16.INNER CASING OR TUBING eothermal closed-too
2.WCII CDnStrnCllOn Permit#: ��/V O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Parlance,etc.) es ft. ft. !in. . /bL' /ed�✓
3.Well Use(check well use): ft. ft. in. !Y� elrr
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. tt. in.
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01r1 ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. a ft. NTorrf
❑Monitoring ❑Recovery % ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
ft. ft.
❑ 19.SAND/GRAVEL PACK if alicableAquifer Storage and Recovery ❑Salinity Barier FROM TO I MATERIAL' 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,hnrdness type,e rain size etc.
0 ft. a ft. T S .L
4.Date Well(s)Completed: /G aoZ Well ID# ty ft. 9a ft. n t L
5a.Well Location: ft. j tt. l7 1` i ST
_Sib ?1W1 Dates JNC ft. ft. G
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
Voo N C_ f4w. 3f ZEa�rco,� me rt. ft.
Physical Address,City,and Zip d 7 q7 ft. ft.
I R,S/VKL t IF;1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiftcat•
6.Is(are)the well(s): ®Permaneut or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby certify that the mell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0No ISA NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on tire back ofthis farm.
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 constriction info
constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBD4ITTAL INSTRUCTIONS
9.Total well depth below land surface: • $ (ft.)
For multiple wells list all depths!fdierent(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
Q Q (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (inJ 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-Loon Geothermal Return Wells:Copy to the
(i.e.ganger,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.field ro BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) �� Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018