GW1-2022-03588_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips ,4:WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3441A S- ft. 1 /.20 ft. /SGy�tit
ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name 4-)ss ft. 196.5 C'ft. % fa PAL v
0000 6 D 16.INNER CASING OR TUBING eothermof closed-loop),
2.Well Construction Permit#: 15�(� FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): H. ft. in.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public O & /a0 ft. in. ak �'.S 0 vL
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. ft. in.
❑htdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. Pd ft- afrwroNi//F pemlzr4,
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage St9 ft. a0 ft. �3 a 1zA.t�L
❑Experimental Technology ❑Subsidence Control ft. mt
❑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,hardness soillretk type,grain size etc
O ft. a ft. 7_ L
4.Date Well(s)Completed: /— /—OttXq��a�Vye„�# a ft. ga ft. 4 ��
Sa.Well Location: ft. IDS ft. SANS s i oN� SLATE
A&GIL (4AJ-ALLcf7E ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft
/33 S0 FACI f /2/0&e bR' ZE<3t i Lon/1v e ft. ft.
RECENED
Physical Address,City,and Zip a7s!/ ft. ft.
/'t
dTff 21;REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: pwplaoa
(if well Seldom,o7neGl�aUlong is su
ff dent) 2 2 22.Certiliea'
6.Is(are)the weil(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the'vell(s)'vas(were)constructed in accordance'vith
7.Is this a repair to an existing well: ❑Yes or LINo 15A NCAC 01C.0100 or 15A NCAC 02C A200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of the ofthis record has been provided to the ivell owier.
repair under#21 remark section or on the back of this 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �3,S (ft.)
For multiple hrells list all depths ifdii ferent(example-3@200'and 22@100) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: C Q (R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water 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(fUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su t and O en-Loo Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push etc.) county environmental heal epartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) �S Method of test: Blow Permit Program,1611 MSC,Raleigh,!NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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