GW1-2022-03709_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 I DESCRIPTION
3441 A Q S ft• b ft.
ft. rt
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THIC ES MATERIAL
Company Name
It-
ft. in.
� ,
// 16.INNER CASING OR TUBING(geothermal closed-lor
2.Well Construction Permit#: (� FROM TO I DIMIETEA THICKNESS MATERIAL
List all applicable ire/l construction permits ri.e.WC,County,State,Variance,etc.) R. ft. 10.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 11 SCREEN:
FROnI TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. R. id
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) It. ft. in
❑kndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO nATERIAL EnIP CEnIENT nIETHOD&MIOUNT
Non-Water Supply Well: D ft. D ft. ` (`
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. tr.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicableFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return ❑Other ex lain under#21 Remarks FROM To DESCRIPTION eofor hardnea aoiUrock a ra a aiu etc.)
ft. e, ft. /
4.Date Well(s)Completed: —I -2 Well ID# ft. ft 4
5a.Well Locatior i ft ft. ��/�
'K 1 1 ►1 k/4''4 �R' ft. fL
Facility/Owner Name Facility
rIDD#(ifapplicable) ft ft
l J U mP �cfA (A'A Tin l" ft. ft. )►-
Physical Address,City,and Zip f/!f ft. ft.
J0hA5fVn tJ[s / 21:REMARI{S
Count' Parcel identification No:(PIN) 1 7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: « ''^• ` "'
(ifwell field,one W/long is sufficient) 22.Certificat• „ Ui
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerrt&that the ivell(s)was(n•ere)cmrstmcted in accordance tiith
7.Is this a repair to an existing well: ❑Yes or ®No I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature of the ofthis record has been provided to Ilia ivell owner.
repair wider 921 reinorks section or on Ilse 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: I
3 J 5 fL 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ram`
f a•multiple wells list all depths ifdprem(example-3@200'mid 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 26 ft 24a. For All Wells: Original form to Division of Water Resources (DVVR),
Ifu•aler level is above casing,use^+'L ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: y (in,) 24b.For Injection Wells:Copy to,'DWR,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:Co to the
(i.e.auger,rotary,cable,direct push etc.) cointy envronmental health department of the county where installed Copy
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producing over 100,000 GPD•Copy to DWR,CCPCUA
(gP
13a.Yield nr) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Ib.
i
Form GW I North Carolina Department of Environmental Quality-Division of Water Resources 1, Revised 6-6-2018