GW1-2022-03629_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 DESCRIPTIONft. ft. /h
3441 A 190
C(Q ft. It.
Well Contractor Certification Number 15.OUTER CASING for muMcase `ells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
fL ft. in.
Company Naive `
W _ b 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FRONT TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): rt. ft in.
Water Supply Well: 17.FRO TREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mwmicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL FMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT 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)
❑Geothermal(Heating/Cooling Return) ❑Otlmer(explain under 421 Remarks FROM TO DESCRIPTIONcolor hardness soillrock type,grain siu etc.
tt. It.
Gr n t
4.Date Well(s)Completed: —/ -ZC Well ID# ft. ft.
Sa. \'ell Location: ft. ft.
1
Ilk I
ft ft a
Facility/Owner Name ((("` '1�) Facility ID#(ifapplicable) / ft. ft.
MAR
' I/ D
Physical Address,City,and Zip 82 '7,51 ft. ft. It>�t4�Itation F'fII G:1tIq UM
' /i //y 21.RE51ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil field,one lat/lof is suffic'ent) 22.Certifrcat' r:
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the ivell(s)was(mere)constructed in accordance triih
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C;0200 Mell Construction Standards and that a copy
Ifthis is a repair,.ill out knotrn meld construction information and explain the nature ofthe ofthis record has been provided to the mell onder.
repair under 921 rentarls section or on the back of this fornn.
23.Site diagram or additional well details:
3.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
constnlction,only I GW-I is needed. Indicate.TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 9.Total well depth below land surface: ft�� � ( .
For multiple wells list all depths ifdi ferent(example-3@200'annd 2@l00') ) 24.SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top ofcasing: �) (ftJ 24a' For All Wells: Original forrri to Division of Water Resources (DWR),
If ureter level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to I)WR Underground Lljection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supp1Y 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 SUPPLY20 ELLS ONLY: 24d.For Water Wells producing otter 100,000 GPD: Copy to DWR,CCPCUA
1.3a.field(gpm) Alethod of test: BIUW Penntt Program,1G11 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources i Revised 6-6-2018