GW1-2022-05553_Well Construction - GW1_20220603

FELL CONSTRUCTION RECORD(GW-1), For Intemal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATERZ.ONES.
Well Contractor Name FR011f TO DESCRIPTION
3441 A ft tt. 0 O M
ft. ft.
NC Well Contractor Certification Number
15:OUTER'CASING for multi-cased wells OR L R if a licable
NW Poole Well and Pump.Company FROf11 TO DIAMETER THICKNESS NIATERIA
ft. ft. is
Company Name
w�O 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: [/ OC G FRODI TO I DIAMETER THICKNESS 5ATERIAL
List all applicable ire//construction permits(i.e.UIC,County,State,Variance,etc) ft.
3.Well Use(check well use): ft. ft. is
17.SCREEN
Water Supply Well: FRO51 TO DIAIIIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
❑hidustrial/Commercial ❑Residential Water Supply.(shared) 18.GROUT
01rr1 ation ❑Wells>100,000 GPD FROM TO 51ATERUL Eh,,,f4NIENT METHOD&AMOUNT
Nou-Water Supply Well: ft. tt. 4_l2
❑Monitoring ❑Recovery ft. tr.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft.. ft.
19:SAND/GRAVEL PACK If a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FR011I TO I 11IATERIAI I EIIIPLACEnIENT 11fETf10D
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothenual(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness •soil/rack e,grain size,etc.)
% tr.
4.Date Well(s)Completed: _A-22 well ID# ft. ft.
5a.Well Location: ^ ft. sft. r�.n
C JW r (�• ft. ft
«ttJJJJ����� •�
Facility/Owner Name Facility ID#(iiff applicable) ft. ft. r .^A It •.' q'� p
i2.!l/I e I k ft. ft.
Physical Address,City,and Zip�— V— ft. It.
21:REMARKS
County Parcel Identification No.(PIN) h•,�►1;��•.�e5
i"v
5II.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certifica
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)Iras(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANo 15A NCAC 02C.0100 or iSA NCAC 01C.0200 iI'ell Construction Standards and that a copy
t0his is a repair,fill out known ire/l construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under f.21 remarks section or on the back ofthis fora.
23.SIte diagram or additional well details:
3.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: 1
^��` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l9v ft,
For multiple ivells list all depths ifdiifferent(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 of easlug• (iV (ft.)
24a. For All Wells:'Original form to Division of Water Resources (DWR),
Ifrraner•level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Iz.Well construction t method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.anger,ro ry,cable,direct push etc.) county environmental health department of the county where installed
FOR-WATER SUPPLY VV LLS ONLY: 24d.For Water 1Vells Droducint over 100,"'GPD:Copy to DWR,CCPCUA
/ BIOW Permit Pro—gram,1611 MSC
13a.Yield(gpm) � Method of test: � � ,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
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Form GIV-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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