GW1-2022-03634_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 I DESCRIPTION
3441 A 115 ft. 1&0ft. 2 m
ft. ft.
Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ble
NW Poole Well and Pump Company FROM TO DLIMETER Tica
THICKNESS MATERIAL
Company Name t
I It. 7 ft. / in. •'g Vvt^C
G �J/ 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 7 O / FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,State,irariance,etc.)- ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREEN.TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft is
❑Geothermal(Heating/Cooling Supply) IV Residential Water Supply(single) ft. R. in.
❑industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO 3ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20 ft. Dad
❑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 MATERIA I 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 RetuReturn) ❑7Other explain under#21 Remarks) FRO51 ft. tt TO DESCRIPTION color,hordness soil/mck min size'etc.L
L.00
4.Date Well(s)Completed:3-16`Z[ Well ID# ft. ft. t
5a.Well Location: ft. zo <1
ft.
ft ft.
Facility/Owner Name I Facility ID#(if"
ft. ft.
b� Sti!n fi � 4 I Wilk/ ft. ft.
Physical Address,/City,and Zip R" J(t/� / ft. ft.
tNwi�l a�a$9z 2LREMARKS
���
County Parcel Identification No.(PiN)
lre�oat>f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) �7 l- 22.Certificat' M:
3 S-�l-f ; N ( �•lo� W 3 _ 4-Z Z
6.Is(are)the well(s): (&Permanent or ❑Temporary Signature ofCerti6ed Well Contractor ` Date
By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction Information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks 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 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: t+ (ft.)
For multiple wells list all depths ifdoerent(example-3@2�070'ajnd 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 249. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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
t
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing 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.
Form GW-l North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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