GW1-2022-03708_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 DESCRIPTION
3441A 37011' 37fft. G
rt. rt
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FRO TO DIAMETER THICKNESS MATERIAL
• ft. 03. ft Company Name
q 16.INNER CASING OR TUBING eotherma[closed-loop)
2.Well Construction Permit q: 3 FROM TO DIAMETER 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): 1't. ft. 1n.
Water Supply Well: 17. BEEN.
FROM TO DUMETER 'SLOTSILE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) )Q(esidential Water Supply(single) ft. fr. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD A,AMOUNT
Non-Water Supply Well: Q ft. ft. 0 __PkR1Fh1
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METIIOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets Ifaecessa
FROM TO DESCRIPTION color,hardness soiUrock e, rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain wider#21 Remarks) Q tt tt obsol
4.Date Well(s)Completed: 4179Well hD# I,. ,S tt 5AA00 4 G
rt rt. �sRR' Qtft.Sa.Well Location: �f e
Sa S %TG
Lj` �T t 411 k- f7Un'I G S ft. ft
Fac' ty/Owner Name Facility ID#(if ap licable) ft. ft.
th im6, r �Lo7-3 ft. ft.
Physical Address,City,mid Zip ON NC a7�7 tt. ft.
FRAM kG� ( 21.REMARKS
County Parcel Identification No.(PiN) L-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(ifwell field,one lat/long is sufficient) 22.Certifreat' �4�z
N • 3bIW
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCcr ified Well Contractor ` Date
By signing this forn,I hereby certify that the ivell(s)ivas(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill our known well construction Information and explain the nature of fire ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis form.
23.Site diagram or additional well details:
SAW 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depthbelow land surface: SO e (ft.)
For multiple wells list all depths ifdii ferent(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: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+•' / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ` (in,) 24b.For Injection Wells:Copy to DWI,Underground Injection Control(IUC)
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 heap department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water We11s roducin over 100.000 GPD:Copy to DWI?,CCPCUA
` Blow Permit Program,1611 MSC,Rale1 ,IYC 27699-1611
13a.Yield(gpnt) l Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-201 S
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