GW1-2022-03622_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 I TO DESCRIPTION
3441 A 9,q0 t`' IaTSf` 20 . PM
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERLIL
Company Name /� ^��i 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: (/S 70 (Q^ ZO Z FROM TO DIAMETER I THICKNESS J MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) ft.J ft. in.
3.Well Use(check well use): m I ft. in.
Water Supply Well: 17.SCREEN,
FROM TO DIAMETER (SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Xesidential Water Supply(single) R ft ;ry
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Itrl ation ❑Wells>100,000 GPD FROM I TO l ERIAL EAIPLA MENT METHOD&AMOUNT
Nou-Water Supply Well: ft. 20 ft. AW
�tJ
❑Monitoring ❑Recovery fL ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑ 19.SAND/GRAVEL PACK if applicable)Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEaIENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
iUro rain size etc.
❑Geothermal(Heating/Cooling Retum ❑7Other(explain under/!21 Remarks FRO51 TO DESCRIPTION eolor hardness so ft. ft. d i C
4.Date Well(s)Completed:3 ` Well ID# 112
tt. tt.
5a.IWII Location: 17-4
ft. ft.
Sao Aff_c ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
MAR 2
SoZ o y f} l cM Q r d 7dd6 tt. ft.
Physical Address,City,and Zip ft. ft. (flfOf n PrOCOGWO UhR
21.REMARKS
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �J 22.Certin '
3Sr �N 2, W /6-2 Z
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified 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 ©No ISA NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or an fire back ofdris 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t
24.SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: (ft.
For•multiple wells list all depths ifdierent(example-3@200'aann)d 1@100) ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: G✓ (ft.) 249. 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: y (in,) 26.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 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
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FOR WATER SUPPLY W,FLLS ONLY:
vj 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 2 Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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