GW1-2022-03646_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.IVATER ZONES
Well Contractor Name FRO51 TO DESCRIPTION_` g, L ft. />ti
3441 A V l , ! 1
It- r ^
NC Well Contractor Certification Number 12
15.OUTER CASING for multi-cased ells OR LINER if a livable
NW Poole Well and Pump Company FRO51 TO DIAMETER THICKNESS MATERIAL
Company Name
11. 0 C ft. in. . l "IJin
� l y
C9 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: i�-w� of 1 �a 2 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): ft. ft. In.
17.
Water Supply Well: FA0111REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr. ft. in
❑hndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rr1 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Noo-Water Supply Well: ft. ft. /
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(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 soil rock a rain size etc.
ft. nL ft.
4.Date Well(s)Cornpleted: _0?I-Z Z Well ID# ft. tt.
5a.Well Location: ft. ft. l4wlLh.
nsf'k jb�s ft. ft.
Facility/Owner Name Facility ID#(i£applicable) ft. ft.
L6 g 5 54,'11f 5 Nn s way 4/r 1100 A-151 ft. ft.
Physical Address,City,and Zip NL �7J9 2 ft. ft. unit
A is Ilk L 21.REMARKS
Comity V vim" Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one)at/long is sufficient) 21.Certificat' t:
35. 5q3l. N � g 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 irell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IRJNo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
!(this is a repair,fill out known well construction information and explain the nature of the ofthis 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 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C�GI (ft
For nnuhiple wells list all depths ifdtgerent(example-3@200'andd2@100� ) Submit this GW-1 within 30 days of well completion per the following:
(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top ofcasing: ZzIf rater level is abore 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(RUC)
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 S
13a.Yield(gpm) 15' !41 Method ortest: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 1 lb.
Font GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018