GW1-2022-03603_Well Construction - GW1_20220328

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.wATERZONES
Well Contractor Name FROM I TO I DESCRIPTION
3441 A p rr. 2 I rt. lh
ft. ft.
NC Well Contractor Certification Number IS:OUTER CASING for multi-cased weUs OR LINER if a licable
NW Poole Well and Pump Company FROM To DtAD1ETER THICKNESS 91 MATERIAL
Company Name
ft. 1 J 1 ft. L in. - Ip =Ar U'/
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.NC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE TIUCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) >Vesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑bTl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. ft.
❑Monitoring ❑Recovery fr. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. it.
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additioualisheets if necessary)
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soillrock type,gmin size etc.
l l IL
Z rd ". 11a 4�
4.Date Well(s)Completed: Z0' Z. Well ID# tt. ft.
51.Well Location: ft. ft.
ft. ft.
mehmil
Facility/Owner Name Facility iD#(if applicable) ft. ft.
G �af�(;•n ��t�y-e Z� d�Cv� � fL rL
Physical Qdiress,City,an p it• ft.
1 21:RE117ARKS
roccosing link
County- I Parcel Identification No.(PIN) DWQMOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certifieat'
N
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor a Date
� By signs ngrhis forin,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: !`w or ®No 1 SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
Ifdiis is a repair,fill out known ivell construction Information and explain the nature of the ofihis record has been provided to the ivell owner.
repair under#21 remarks 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: � / � ft
For multiple wells list a!1 depths deli ferent(example.3 a200'and 2Q1003 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: O 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(IUC)
Rotary _ Program,1636 MSC,Raleigh,NC 27699-1636
i.e Well construction method: 24c.For Water SupDty 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(gpm) 3 Method of test: BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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