GW1-2022-03728_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. 45 ft. S 6 �
3441 A rs 1 90 fL /S- 'GP-7
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft. S ft. in. A��
Company Name • t •
GrV_ O`/ �, ^ 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: o, �j FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ff. � HL
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17,SCREEN.
pp y FROM TO 1.DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. 1L in
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) n. R ;n
❑industrial/Cormnercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: 0 ft. Q ft. fiCnM#77A
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E51PLACEDIENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geotltennal Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM . TO DESCRIPTION color,hardness sailtrock a rain size etc.
o ft. aft. 7-0 So, c
4.Date Well(s)Completed: 3 a Well ID# ft. 3* ft. s tip k C AV
5a.Well
//Location:
+� ft. 'QS fL GR 1
TE
ft. fL
FacilitylOwne6lame � Facility ID#(if applicable) ft. ft.
AD n Cr ft. ft. r
Physical Address,City aad Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certifrcat'
3�J, r]97�N W l .,3OPOL
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)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 01C.0100 or ISA NCAC 02Ci.0100 Kell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ivell owner.
repair under#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 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /O✓• (n•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100)
• /S 24a. For All Wells: Original form to Division of Water Resources (DR),
/f water level is above casing,use"+"
f Static water level below top of casing: (�) W
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DWI?,Underground injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su I and O en-Lon Geothermal Return�Velis:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health epartment of the county w ere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) o Method of test: Blow Permit Program,1611 MSC,Raleigh NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018