GW1-2022-03621_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.1VATERZONES
Weil Contractor Name FROM TO DESCRIPTION
3441 A 810 r1- 5 ft. < ,Y)
NC Well Contractor Certification Number
0 '1' 61s- It. 16 /f
15.OUTER CASING for multi-case wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MA
TERLIL
fr. ft. ill.
Company Namc
, / 16,INNER CASING OR TUBING cothermat closed-loo
2.Well Construction Permit#: (J' G�" C O 2 FRO51 I TO DIAMETER THICKNESS MATERIAL
List all applicable'veil construction permits O.e.UIC,County,State,Variance,etc.) ^1" fI. _ fL is . (r 1Y' "�i�i
ft.
Well Use(check well use): fL t Q
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ve-idential Water Supply(single) ft. R, in.
❑hndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irrigation ❑Wells>100000 GPD FROM TO MATERIAL EMPLAC MENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z v ft. tJlf `•
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation rt. ft.
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional streets if necessary)
❑Geothermal(Heating/Cooling Return) 1L 2 rt.❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardness soiVrock a rain s' eta
10 '� 6
4.Date Well(s)Completed: / -G 1-2 ( Well ID# ft. J! ft. C e-
s ft. ft. %4 dr i1
Sa.1Ve11 Location: ' `-'-
- �k• 4-/r ft. ft. -
e)ca app(
Facility/Owner Name FacilityID# if applicable)
fL ft.
8,10 I S�rf Il{ J U C, >,} i Iv W 's nJ fL rL 202
Physical Address,City,and zip .N C o1 75 2 1 ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificat' tt:
31ID-.S413as N 6099 C O�e W C -z
6.1s(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forin,I hereby certify that the'vell(s)'vas(here)constructed in accordance'vith
7.Is this a repair to an existing well: ❑Yes or ®No 1 SA NCAC 01C.0100 or I5A NCAC 01C.0100 ifrell Construction Standards and that a copy
If this is a repair,fill out Inm'vn'vell construction information and explain the nature of the ojthis record has been provided to the spell onvrer.
repair under 921 remarla section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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: n 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - `
For multiple'pells list all depths tfdi,/ferent(example-3@200�d 2(a�100) ( ) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: C//� ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If rater level is above casing,use' Information Processing Unit,1617 MSG,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Inlectioq 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 Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPL71 W LLS ONLY:
I 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
(gp ) Method of test: it
13a.Yield m Blow Perm Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6.6-2018