GW1-2022-03640_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips HtWATER ZONE,
Well Contractor Name FROM TO DESCRIPTION
3441 A '305 ft. 310 ft. Z7p^
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased weds OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name I I rL '70
rr in: &d— 1 A I vj;-t
16.INNER CASING OR TUBING feeothermal closed-looril
2.Well Construction Permit#: U w" �J J�/ �Z 1 FROM TO DIAMETER I THIMIESS-7 MATERIAL
List all applicable.veil construction permits 0.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M tcipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. v/
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if a ticable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage tt• ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soiUmck rain size etc.
O ft ft.
4.Date Well(s)Completed: -Zb..Z f Well ID# 2 ft. 45 ft.
5n.Well Location: C ft.
�O
Fain� CR f yt if_rs" ft. ft.
Facility/Owner Name
i/ „ ��j�i Facility ID#(if
+applicable) ft. ft. i
5� V 1 ;Y a V"L'k L t pw e,(�k ft. ft
LMAR
Physical Address,City,and Zip ft. ft.
2L REMARKS c
County lA Parcel Identification No.(PIN) CKNOMOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certificat'
3� 1 N -- 7 70 ► W d
6.Is(are)the well(s): ®Permanent or ❑Temporary Sign/attire of Certified Well Contractor ! ` Date
By signing this fornt,I hereby certify that lite ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information mid explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks 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
S 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: C) ft) 24s. For All Wells: Original form fo Division of Water Resources (DWR),
If water level is above caring,use"+' ( Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniectiog Wells:Copy to DWR,Underground Injection Control(NC)
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
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gp m) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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