GW1-2022-03612_Well Construction - GW1_20220328

WELL CONSTRUCTION'RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 1a.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
3441 A 176 ft L rt.
rt. rt
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
rr. U rt. in. I C'i J::.t
Company Name 7 16.INNER CASING OR TUBING cothermal closed-loop)
(�)
2.Well Construction Permit#: ""6�OS I 2-C 2 � 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): ft. ft. in.
17.
Water Supply Well: FROM SCREEN,TO DIAMETER SLOT SIZE THICKNESS -MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. V ft. o u.p1 I t
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRoat I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I To DESCRIPTION color,hardness soillrock t rein sire etc.)
U ft. ft
4.Date Well(s)Completed: 79-Z I Well ID# ft, tt.
5a.Well Location: ft- 225 ft.
E �firn
Gt'1d Y Li h i �{ ft. ft. � ml
-
Facility/Owner Name Fa *1* ID#(if applicable) ft. ft.
)Sol 6 )d �/ kt 5 12 ft.
MAR 2
Physical Address,City,and Zip 7 /Z tt. ft.
vtI 21:1tEMAItKS
\/
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onesllat/long is sufficient) 22.Cerifca
35'- a N -79• 5 (D� W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified well Contractor s Date
By signing this form,I hereby ceriffy that the well(s)was(here)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 Well Construction Standards and that a copy
If this is a repair,fill our brown well construction information and explain the nature of the of this record has been provided to the well 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You'may also attach additional pages if necessary.
drilled: t 24.SUB11=AL INSTRUCTIONS
9.Total well depth below land surface: C�J ft.)
For multiple wells list all depths ifdiflerent(exanhple-3@200''aa�nd 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),
Ifwater level is above casing,use'4" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Infection 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-Lon 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 over100 OOD GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,VC 27699-1611
13b.Disinfection type: I-iTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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