GW1-2022-03706_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
3441 A S75
ft-
ft• A
NC Well Contractor Certification Number a. I ft
15.OUTER CASING for multi-cased we OR LIVER if a livable
NW Poole Well and Pump Company FRO51 TO DIAMETER THICKNESS MATERIAL
tr. ". In. . ( G,It1t�
Company Name ,
r_ 16.INNER CASING OR TUBING eothermal closed-loonl
2.Well Construction Permit#: `� FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable Well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): n. ft. in.
Water Supply Well: 17.SCREEN.
l/P FROM TO DMIETER ..SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipaublic R• R. in.
❑Geothermal(Heating/Cooling Supply) iesidential Water Supply(single)
R. R.❑industrial/Commercial ❑Residential Water Supply(shared) in
lli GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO rJATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. tt.
AdW-_ [d0Q2
❑Monitoring ❑Recovery ft ft.
Injection Well:
❑A uifer Recharge fr. ft.
9 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑$alini Barrier 19.SAND/GRAVEL PACK if a livable
�' FROM TO I MATERIAL I EMPLACEafENTMETHOD
Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. tt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLWG LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other ex lain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/reek t rain size etc.
ft. ft.
4.Date Well(s)Completed: Z-Z S"2Z well ID# ft. Z ft.2
5a.Well Location: Z r ft. /JVt.
YV`I De TNO(nto11 fL v ft
F cility/Own Name Facility ID#(if applicable) ft. ft
�16 olden DurNuo% NC a-77o3 •, ��� r
rt. ft.
Physical Address,City,and Zip ft. ft. MAR 3 0 -
ir 21:REMARKS
t;
County Parcel Identification No.(PIN) ,.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one hit/long is sufficient) -7 p 22.Certifiea
Ja� • � 7Z N �
W 2_yf.zZ
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature=1ifiedWell Contractor Date
By signing this form,l hereby certtry that the.well(s)o•as(Were)costructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No ISA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standard[and that a copy
1f 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 ender#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 tojprovide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: r f✓5 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft.
For multiple wells Its[all depths ifdii erent(example-3@200'and 1@100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 1 (B) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaler level is above casing,use" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (iD,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:(i.e.auger,rotary,cable,direct push 24c.For Water Supply and Open-Loup Geothermal Return�i'e'is:Copy to the
etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells aroducine over 100,000 GPD• Cop
y to DWR,CCPCUA
13a.Yield(gP m) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i