GW1-2022-03608_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 S S It. ba ft. ! �►.,n
j1- ft. Q ft. S i+
NC Well Contractor Certification Number b
15.OUTER CASING for multi-cased wells OR LINER if a liable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
rt. U rr. in. i Q tt1n.. C
- Company Name
L /� 16.INNER CASING OR TUBING cothermal
V closed-loo
2.Well Construction Permit#: u w- SS_3 YS -2 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits( U/C,County,State,Varlance,etc.) ft• ft. is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN.
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft R in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑WeIIs>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft, a ft. Q ft P (jll r
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation tr. ft.
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. I ft.
❑Experimental Technology ❑Subsidence Control ft, I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hnrdness soiurock e, rain size etc.
it. a ft. I
4.Date Well(s)Completed: 3_ 2 Well ID# ft. ft. AIL V t
51.Well Location: < ft.
kGl(_0(1 j C)St'f'fllI ft. ft
Facility/Owner Name Facility ID#(if applicable) ft• ft. e
7 S 0/ 12 4.i y/C( IZu�c� �b✓/�� /tic ft. ft. MAR -2 9 2g22
Physical Address,City,and Zip Z 75117 ft. ft.
�/; 2LREM
v ARKS I ili8iti7n roC�iC3^
�ke,
County Parcel IIdentification No.(PIN) DWID/80G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Held,one lattlonnig is sufficient) 22.Certifreat'
'�
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature ofCeni6ed Well Contractor Date ..
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Mell Construction Standards and that a copy
Ifdhis is a repair,frll out known well construction information and explain lire nature ofthe ofthis record has been provided to the well owner.
repair under#11 remarks section or on die back of dUs 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: M S (ft.)
For multiple wells list all depths ifdoerent(example-3(200'and 1@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),
If,raner level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I I.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\Yells: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(gptn) ) Method of test: BIoW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6.6-2018
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