GW1-2022-03726_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 ft. tL
NC Well Contractor Certification Number
S rt
?0 ft. ? . !h
IS.OUTER CASING for ran i IER(ifau licable
NW Poole Well and Pump Company FROM TO DIAME ER THICKNESS MATERIAL
Company Name tt• 87 ft. in. i Z`f J.�(41()k-j
('�L� /)j r Jl/IIOQgg/Z 6.INNERCASING.ORTUBING eothermalclosed-luoo(J
2.Well Construction Permit ti::_(I(GU ) rl �/ /l 7 7 LL FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. h
3.Well Use(check well use): it.
Water Supply Well: 17:SCREEN.
FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
❑Agricultural $Municipal/Public g tt in
r7Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. tt. in.
Andustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT_
❑Irri atioll ❑Wells>100,000 GPD FROM TO AMTERIAL E51PLACEAIENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft W/�i l✓�
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ft. ft.
9 g ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier 7m.
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLWG LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardness soiu ck type,grain size etc.
ft. ft.
4.Date Well(s)Completed: Well ID# ft,
Z ft.
5a.Well LoV110 ft. Q f►• r
ft. ft 601
Facility/Owner Name Facility iD#(if applicable) ft. ft.
Physical Address,City,and Zip ff, ft. M n R 1
l/)0-U 1 21:REMARKS H
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(�I field,one lat/1 g is1sulFcient) A �f p�((� 22•Certiflent
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby cert fy that the ivell(s)u•as(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IINo 15A NCAC 01C.0100 or 15A NCAC 02C.0100[yell Construction Standards and that a copy
If this is a repalr,fill out known ivell construction ii formation and explain the nature of the ofthis record has been provided to the well owner.
repair wader 921 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:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ �� (ft.)
For multiple mel/s list all depths ifdierent(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: Z 24a. For All Wells: Original form to Division of Water Resources (DWR),
ifn•ater level is above casing,use"+^ (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
11.Borehole diameter: (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 Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmenta heal epartment of the county where installed
FOR WATER SUPPL WELLS ONLY: i
24d.For Water Wells producing over 100 000 GP
Copy to DWR,CCPCUA
13a.Yield m BIOW Permit Program,1611 MSC,Raleig ,NC 27699-1611
(gP ) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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