GW1-2022-03611_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 I tol ft. rr.
NC Well Contractor Certification Number
Z� rr. j rL
NW Poole Well and Pump Company 15.OUTER CASING(for multi•cas e s ORLINER ifa licable
FROM TO DIAMETER T111CKNESS MATERIAL
ft. ft. in.
Company Name
W_ 0 S n O 3 9^Z O 74 16.INNER CASING OR TUBING eothermal closed-100131
2.Well Construction Permit#: d FRont To DIAMETER THtctavESs I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Parlance,etc.) ft. ft. in, ls[ s/ Y�/_ )
3.Well Use(check well use): ft ft. in. U iJ �C'
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER -SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) tt tt in.
❑Industrial/Commercial �Residential
residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells>100,000 GPD FROM TO MATERIAL Erffj&CEMENT METHOD&M10UNT
Non-Water Supply Well: ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ifalicableFROM TO I MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothenmal(Heating/Cooling Return ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness so l/mck a min siu etc.
ft. ft. O D t
4.Date Well(s)Completed:- 'ZZ Well ID# ft. ft.
5a. Yell Location: ft. ft f,
C& fL ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5 i a 1 VA DE, J2� 11.�f A ft. ft.
Physical Address,City,and Zip t/ ft. ft.
141 It i 21.REMARKS n f/Q,
County �, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellLfield,one fat/long is sufficient) �( 22.CertificaC
N 34/I`J
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby eertIfy that the'ivell(s)was(irere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 fr'ell Construction Standards and that a copy
If dds is a repair,fill out known well construction information and explain the nature of die ofilus record has been provided to the well owner.
repair under#21 remarks section or on die 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 tojprovide 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: US ft
For multiple wells list all depths ifdii 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: Zo ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifu•ater 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 hnjection Control(MC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.anger,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) Z Method of test: Blow Perm tt Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Ili.
i
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018