GW1-2022-03586_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A /5r ft. 160 ft. a C
aK ft 'S 6 Ao,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased w OR LINER if a licable
NW Poole Well and Pump Company FROM To DIMIETER THICKNESS MATERIAL
Company Name , '� �// / /�� r•fr�
1�� C (t # 3 ,` 16.INNER CASING OR TUBING eotbermal closed-loop)
2.Well Construction Permit#: CI 16 l•� FROM TO DIAMETER I THICKNESS 51ATERUL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft. fr. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 11.SCREEN.
FRO51 . TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. n in.
❑Geothermal(Heating/Cooling Supply) )dResidential Water Supply(single) ft ft in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: Q ft. 30 It. PA-To ,-w [�
70
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr. 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 fr. ft.TO DESCRIPTION color,hardness soiUrock type,2rain size etc.
4.Date Well(s)Completed: $ (�u� Well ID# ft. ft.
5a.Well Location: fr. fr.
4 EC E WED
ki3 301Lb//VC ✓ fL ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
'SS G", Lk(.VS 1,44 . S�etic �24F ft. ft. Injorpybon P Lh*
Phyysi{fc�Iall Address,City,and Zip �J 7 Q� ft. ft.
`/� 8�1 I "3 1^ f� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell Held;one lat/long is sufficient) ^� e� [� 22.Certifiea"
C Sit J` -ra O
-- �ot W Zv
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerilry that the rvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or i5A NCAC 01C.0100 Well Construction Standards and that a copy
If dais is a repair,fill out known well construction information and explain the mature of die ofthis record has been provided to the well ouver.
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 Ovei'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'S (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.)
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 Infection Wells:Copy tojDWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Mud and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of a county where instal ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test' Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
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