GW1-2022-03643_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 DESCRIPTION
3441 A fc
rt. 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
ft. ft. in.
Company Name '7 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:�T�/�/^ OJ / O / _ Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction pertnits(i.e.UIC,County,State,Variance,etc.) H• ft- in.
3.Well Use(check well use): ft. % in.
Water Supply Well: 17.FROMR, TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential WatezSupply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IrTi ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLA DIENT METHOD&AMOUNT
Non-Water Supply Well: I, UJr-
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft.
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. I
❑Experimental Technology ❑Subsidence Control ft. I It.
❑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 soureck a rein size etc.
ft. ft. I pS d t
4.Date Well(s)Completed: -INZWell ID# yfrt. ft. G' y
5a.Weil Location: -f' ft. vs
�-� ft. fL
Facility/Owner Name Facility 1D#(if applicable) tt ft
G2 r 6cx,end- 3bc ex s Vjc-t/ Wmo W ft. ft.
Physical Address,City,and Zip 5 ✓pr �•/ Nc C •75 f2 ft. ft. DWWOG
� � 1 9 i �7 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certiftcat' P
33. J l�t N - 10 , � V � W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified 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 allo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the mature of the ofthis record has beenprovided 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 M
24,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For nnulliple wells list all depths ifdiJferent(example-3@200'andd2@100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ZO (B) 249. For All Wells: Original form to Division of Water Resources (DWR),
!(water 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
i..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 environmentalhealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water WellsFor Water Wells producing 100,000 GPD100,000 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.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018