GW1-2022-05837_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name - FROM TO DESCRIPTION)
3441 A i I U.1" 17 6
90 ft a 9S% ✓1 M
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM I TO 1 DIAMETER FTHICKULS_1 MATERIAL
4- I R. 7 oZ ft. 6 in. •)a-r Cn l lj/-+�-e
Company Name •• � r
a � _ '16.INNER CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#: w y ���I FRO51 TO DL"IETER THICKNESS MATERIAL
List all applicable well construction pernits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ff• ft to
Water Supply Well: 17;SCREEN
FROM TO DIAMETER I SLOT SIZE-1-THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public it. tt. Ia
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g, it In
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Iry ation ❑Wells>100,000 GPD FROM TO MATERIAL E51PLACERIENT DIETHOD&AMOUNT
Non-Water Supply Well: ft. O-XrD ft. r ��
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRODI TO DIATERLIL EDIPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater.Drainage ft ft
❑Experimental Technology []Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J FROM TO DESCRIPTION color,hardness soillrock type,grain size,etc.)
6 ft. ft. —ro
4.Date Well(s)Completed: - -72 Well m# ft. '1 7 ft C re-,
�
i /' ft C, ft.
ga.Well Location: G iGtY 5C�"ir` L � 45 le-
ft. ft
C�
Facility/Owner Narne Facility ID#(if applicable) ft ft. Q4 r l,— F� D
�`lUb i im�zt•1��-� .I7-ctl�. l���K� • re.�- i(JC rt. rr. �'��t'
Physical Address,City,and Zip 2 755 .7 ft. ft. .,
21.REMARKS _„•r..�+, -
County Parcel Identification No.(PIN) 11 _._.,, .art rc;j>,; •1Ji�i'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat1/lo��nggif,, ris sufficient) 22.Certifica'
O AQ
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date/
By sigrdng this form,I hereby cerOfy that the stell(s)seas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15ANCAC 01C.0100 or 15ANCAC 01C.0200 iVell Construction Standards and that a copy
!(ills is a repair,fill out known hell construction in fornnation and explain the nature ofthe ofthis record has been provided io the well owner.
repair under P21 rentarks section or on the back of this form.
' 23.Site diagram or additional n'ell details:
S.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.SUB14MAL INSTRUCTIONS
9.Total well depth below land surface: t-(ps (f')
Far multiple wells list all depths ifdierent(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 casing: 2-0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If,rater•level is above casing,use"+'•(( Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1.1.Borehole diameter: b (in.) 24b.For Infection Wells:Copy to DWR;Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,INC 27699-1636
12.Well coustruction method: 24c.For Water Su I and O en-Lao Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental ealth epartment of the county w here installe
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
m 13a.Yield
(gP ) Method attest: BIQW Permit Program,1611 MSC,Raleigh,NC 27699-1611
i
13b.Disinfection type: HTH Amount: 1 lb.
i
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018