GW1-2022-03609_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A Jk6 ft' 14 5ft.
NC Well Contractor Certification Number
G tt. fL /Y1
1 .OUTER CASING far multi-cased we s OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAM TER 71[ICKNESS MATERIAL
Company Name tr ft. ft. !;a. r" LAC 0,,,.�.
•�1 16.INNER CASING OR TUBING eothermal closed-low
2.Well Construction Permit 4: O 7O /of ��OZ r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ',,in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ,�tesidential Water Supply(single) ft. ft. in.
❑hndustrial/Commercial ❑`Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO ATE EMPLA PENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. v((
❑Monitoring ❑Recovery fr. [r.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation it. tr.
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I E51PLACENIENT METHOD
❑Aquifer Test ❑Stormwater Drainage tt. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks FROM To DESCRIPTION color nardness solurock m n size etc.
ft. fL O
4.Date Well(s)Completed: ^ -G Well IDH tr. tr. C
5a.Vell Location: ft.
ft. ft
Facility/Owner Name l —f Facility ID#(if applicable) ft. ft.
SV rV (�, n L /1 yt fr. ft.Physical Address,City,and Zip J�/d� ft. ft. �nfanklion PrOCOG•I
G (� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one
)aVl( ss Q
onngg isffi sufficient) �J�j Q� 22.Certifreat'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this fornt,l hereby certify that the,well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction Information and explain the nature ofthe ofthis record has been provided to the well owner.
repair tender#21 remarks section or on fire 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:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _(ft.)
For multiple wells list all depths tfdii ferent(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: 2'0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If,vater level is above rasing,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
12.Well construction method: 24c.For Water Supply and O en-Lob ,Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental nealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
2 0 Blow Penn Program,1611 MSC,Raleigh,NC27699-1611
13a.Yield(gpni) Method of test:
13b..Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I ,