GW1-2022-03633_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 ft. 15 it. !D iom
it it
NC Well Contractor Certification Number 15.OUTER CASING.for multi-casedlwells OR LINER if a livable
NW Poole'Well and Pump Company FROM TO DIAMETER THICKNESS ]/IATERIAL
ft. /O ft. is / L- 11G1:Aee
Company Name v
D..77� 7-ZO 16.INNER CASIN OR TUBING eothermal closed-loo
2.Well Construction Permit#: (r 7 zZ FROM TO DIAMETER TH1CIOESS 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. im
Water Supply Well: 17.SCREEN.
FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Al
esidential Water Supply(single) ft. ft. in.
❑hrdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO A ATERIAL EMP EMENT METHOD&AMOUNT
Nou-Water Supply Well: ft. a ft. ( tw r
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stornwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FRO51 TO DESCRIPTION color,hardness s il/mck a rain size etc.
❑Geothermal(Heating/Cooling Return) �J❑Other(explain under#21 Remarks) ft. fr. j� '
4.Date Well(s)Completed: 2- -2L Well EM ft. ft. C
5a.W11 Location: it.
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
Sir �3 A 1 VA 3r. 214 te.'>� yc ���v ft. ft.
°r
Physical Address,City,and Zip ft. ft. MAR '
21.REMARKS
Y V 1 1 y =9 Unit
County Parcel Identification No.(PIN) IROG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) �yq 22.Certilicat*
35� -7h3 S 7 N "7 �c�1S 1 W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby cert yy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C i02b0 Well 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#21 remarks section or on llte back of this farm. -
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You`may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �D( � (ft.)
For multiple wells list all depths ifati ferent(example-3@200'and 2@100) Submit this GW-i within 30 days of well completion per the following:
10.Static water level below top of casing: 2 (ft.) 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 (in.) 24b.For Infection Wells:Copy to I)WR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I
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 roducin over,100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 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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