GW1-2022-03707_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 TO DESCRHTION
3441 A F
t p ft3NC Well Contractor Cenification Numbert. /41 f ft.R CASING for multl-cased i ells)OR LINER if a livable
NW Poole Well and Pump Company FROM TO D TER THICKNESS MATERIAL
ft.Flo--?—ft-
CAW
Company Name � � 4v
352 ` 16.INNER CASING OR TUBING eothermat closed-loon)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERWI.
List all applicable well construction permits(i.e.UIC,County,State,Parlance,etc) ft.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN.
❑A ricultural FROM TO DIAMETER SLOT SIZE THICKNESS nL1TERIAh
g ❑Municipal/Public g ft in
[]Geothermal(Heating/Cooling Supply) wesidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO DIATERIAI EMPLACEMENT METHOD&AMOUNT
Noll-Water Supply Well: tt. 0111Vft. QQrr-� ON
❑Monitoring ❑Recove I7F��fI�✓I�t�
ry
Injection Well: ft. ft.
❑A uifer Recharge ft. ft.
9 g ❑Groundwater Remediation
uifer Storage and Recovery 19.SAND/GRAVEL PACK if n livable
❑A
9 g ry ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It• ft.
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sbeets If necessary)
FROM TO DESCRIPTION color,hardness solitrock a rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
�!/� �f �1 O ft. ft. A'• stl
4.Date Well(s)Completed: (/ sS t of Well EM ft. ft S A i 6l
Sa.Well Location: It 45" ft. in'.-Mr E -fir
SDI�a� 1-1/7p ,AWOFs ft. ft.
Fac'uy/Offwner Name Facility ID#(if applicable) ft. ft
[ICJ ,WC 111hZ 1 ���/lE'��` it. ft. r:r
Physical Address,City,and Zip ft. ft.
�N kt I tAd 21i REMARKS
County `� Parcel Identification No.(PIN) I p.z-i ;-••:;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,onne lat/l�on(g is sufficient) �( 22.Certifica'
�J . `CO N _3U ` � ) W �Ar
A�
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature 'Ca
Well Contractor DateP/
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 AN0 15A NCAC 01C.0100 or 15A NCAC 01C.0200 lPell Construction Standards and that a copy
Ifrhis is a repair,fill out knoum well construction li formation and explain the nature oftre oftlds record has been provided to the well owner.
repair under#11 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'm Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /v (ft.)
For multiple wells list all depths tfdii ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top ofcasing: pL G (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifunler level is above casing,use"+" / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: p (in,) 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 etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department oflhe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducin¢over 100 000 GPD•Copy to DWR,CCPCUA
13a.field(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 1 lb.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018
i