GW1-2022-03637_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14:.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A I`0 ft. JK ft. Z
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM T DIAMETER THICKNESS MATERIAL
Company Name16/
2.Well Construction Permit#: 1/_� tii" CJ Z 'FROM
CASING OR TUBING eothermal closed-1
FROM TO DIAMETER THICKNES.S
S 11 MATERIAL '
List all applicable well construction permits 0.e.Ta7C,County,State,Variance,etc.) ft ft is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Mu cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) f. ft. in.
❑bldustrial/Commercial ❑Residential Water Supply(shared) I8i GROUT
❑IITI ation ❑Wells>100,000 GPD FROM TO MA EMP EMENT METHOD&AMOUNT
Non-Water Supply Well: & ft. Z U ft. , �� r
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
7�4
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACx if a livable
[FROM
M TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer DRILLING LOG attack additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) T DESCRIPTION color hardness soiilrock rain size etc.
ft rt. e Sd 1 C
4.Date Well(s)Completed: 3U' well ID# tt. rt. C. c t,
5a.Well Location: 6 tr. _ft. �__n ——
t
k S L G n S'f (r-�f tr y„ rt. ft. J
Facility/Owner Ngame ` `� .r Facility ID#(if applicable) ft. ft. 5r
I C I 51 � -for(O 11 cl R_(tr,e I J\IrlC_ ft. It,
Physical Address,City,and Zip U 'T 6 ( -ft. ft.
MAR 2
W /,,&,l'K� 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/10n is sufficient) 22.Certifreat'
ef
6.Is(are)the weil(s): ®Permanent or ❑Temporary Signature ofCertified 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 IBA NCAC 02C.0100 or 15A NCAC 02C.0300 Well Construction Standards and ilia[a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofhhe ofthis record has been provided to the well oivner.
repair under#21 remarkr section or on the back of this 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 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: t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells psi a!!depths tftlierenr(example-3@200'and 2 /00D ( ) Submit this GW-1 within 30 days of(Yell completion per the following:
10.Static water level below top of casing: (ft 24a. For All We1Ls: 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(TUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.well construction method: 24c.For Water Su 1 and O en-Loo e
Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where tnstal d
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells aroducing over!!100,000 GPD•Copy to DWR,CCPCUA
13a.Yield m —2 U BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP ) Method of test:
13b.Disinfection type: HTH Amount 1 lb.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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