GW1-2022-03620_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 17 00 rt 1 7 tt`1
tofi
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased we0s OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. ft / in. (tit d11�
�] Q 16:INNER CASING OR TUBING 'eothermal closed400
2.Well Construction Permit#: `T W`06 a Oil /-&2- I FROM I TO I DIAMETER I THICIOESS I MATERIAL
Lint all applicable ivell construction permits(i.e.UIC,County,State,variance,etc.) n- ft
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN:
FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft 4 1n
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IITI ation ❑Wells>100,000 GPD FROM . TO M1fATERIAL EMPL MENT METHOD&AMOUNT
Non-Water Supply Well: ft. fr. V(L OL/(
❑Monitoring ❑Recovery ft. ft.
Injection Well:
tr. to
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt•
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color hardness soiUmck rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks ft- trI—OP r
14 ! t;
4.Date Well(s)Completed: 14 -Zt_ Well ID# tt. ft G
5a.AWell Location:
eft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
Willdw S�y ft. ft.
Physical Address,City,and Zip N L aS 9 Z ft. ft.
V
1 AV'A 1(4— .21.REMARKS County Parcel Identification No.(PIN) 10 Proceszing Unit
5b.Latitude and longitude in degrees/minutes/secoads or decimal degrees:
(ifwell field,one hit/long i's��suicie�nt 22.Certifrca'
353N — W '(gg-7 3Z— W 00,
—Z7—�
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCettified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or RNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200!fell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 rennarki•section or on the back ofthis 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: t � /�� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1u( —(ft.)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: �[� (BP) 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: X7 (�,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Supply 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(gpin) ' SO Method of test: BIOW Perm H Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
i
l