GW1-2022-03641_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips la•WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A ft. fc.
rL ft.
NC Well Contractor Certification Number 15..OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER rHICKNFsS MATERIAL
ft. n.
Company Name , —ti
/ W �S p/��w�� 16.I ER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: (T 7f� Z FROM TO DIAMETER THICKNESS MATERIAL
Lisi all applicable hell construction permits(i.e.UIC,County,Sate,Variance,etc.) ft ft. is
3.Well Use(check well use): ft.
Water Supply Well: 17.SCREEN.
FRO51 . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
❑Lrdustrial/Commdreial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO A ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. J
❑Monitoring ❑Recovery fL ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifavolicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiUrock a rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks is tt
4.Date Well(s)Completed: —) -Z.Z Well ID# ft. ft. ,t
51.Well Location: ft. v ft. u�i��_
o n s i' hofts ft. ft
Facility/Owner Name /`L Facility W#(ifapplicable) ft. ft
p i-
f (/n
- � ,5CA14 rt. ft.
Physical Address,City,and Zip W Ne—
�l(0 J 01.1151 ft. ft.
Of r/t� 2L REMARKS.
mty Inforou ion Procoozing Unit.
LVANNOLYU
Coounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/miuutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiticat'
3� .5 N `-7 6� W /? -�
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,l hereby certify that the ael/(s)tras(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or inNO ISANCAC 01C.0100 or ISANCAC 02C;0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has beenprovided to life 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 l 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: L90-5— Ut.
For nndtlple wells list all depths ifdierent(example-3Q100'a»d2@100� ) Submit this GW-I within 30 days of well completion per the following:
e2 (ft) 24a. For All Wells: Original form'to Division of Water Resources (DV,
10.Static water level below top of casing
Irvafer level is above casing,use"+•' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (i0,) 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 post,,etc.) county environmental health department of the county where installed
FOR WATER SUPPLE/ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpmi) v 6 Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: f-ITH Amount: 1 lb.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018