GW1-2022-03642_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon PhIIIIpS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A ( n- /7 fL 6
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for.multi-cased ive0s OR LINER if a ticable
NW Poole Well and Pump Company FROM fr /� f6 DLIMETERrn Tft1C��S MA`EA�L
Company Name
/` , ' 16.INNER CASING OR TUBING eothermal dosed-loop)
Z.Well Construction Permit#: [J yV s CAS y�`�p2 © FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fa ft. in.
Water Supply Well: 17:SCREEN
FROM I TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) .<esidential Water Supply(single) ft ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) 1s.,GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT a1ETHOD&AMOUNT
Non-Water Supply Weil: tt. V ft. r r
❑Monitoring ❑Recovery ft. fr.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothenmal(Closed Loop) ❑Tracer -20.DRILLING LOG attach additional sheets If necessary)
FROM TO DESCRIPTION color,hardness soll/rock rain site eta
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks ft. ft.
So t,G
4.Date Well(s)Completed: a 2 Well ID# r4ft. q ft. Z It t
5a.Well Location:
Ne f r;(I Nryw,S ft.
Facility/Ownelt} ne Facility ID#(if applicable) ft. ft. a
170L A I/ere-f-k- i L&L -RyLe-- Nc ft. ft.
Physical Address,City,and Zip 7 C G ft. ft.
WAl J/ 21;REMARKS rDC6I.
D��IQI�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneellat/loon�g is sufficient)3 22.Cerrtificc t'S• 1 l N ~-7UQ'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor s 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 InNo 15A NCAC 01C.0100 or 15A NCAC 02C 10200 Well Construction Standards and that a copy
Ifthis is a repair,fill out Mtown well construction it formation and explain the nature of the ofthis record has been provided to the well ouver.
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
constnlction,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: 1 ( C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �LI J (ft)
For multiple wells list all depths ifdii ferent(example-3 t@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: 20 (fG) 249. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaier 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 Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: We 24d.For Water lls roducin 0
ver.'02 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
BIOW Perm Program,1611 MSC,Ralelg ,iNC 27699-1611
13b.Disinfection type: f ITI I Amount: 1 lb.
t
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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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