GW1-2022-06386_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO. DESCRIPTION
Well Contractor Name `
3441 A / rt. ft.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for tnultl-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIA ETER THICKNESS MATERIAL
ft. ft. In. I t 0 5 G(U{
Company Name /� i ,` 16.INNER CASING OR TUBING eothI closed-too
2.Well Construction Permit#: a 1/66 1 6 70-5 FROM TO etvte
DIAMETER THICKNESS MATERIAL
Dst all applicable yell construetionpernrils(i.e.UIC,County,State,Valiance,etc.) ft. ft. in
3.Well Use(check well use): ft. ft. in.
Rater Supply Well: 17.SCREEN
PP Y FROM TO DIMIETER'', SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) XIResidential Water Supply(single) ft. ft. in.;
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT tETHOD&AMOUNT
Nou-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLWG LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRO51 TO DESCRIPTION col hardness soil/rock e, rein size,etc.)
ft. ft. 50
4.Date Well(s)Completed: `` -ZZ Well ID# ft. 03 ft. 4 '-t t
5a.11'eli Location:
U 7 ft. t.2 ft. "�_')J.
Ice ':3-U A4 S ft. It. .
Facility/Owner Name Facility ID#(if applicable)
ft. ft. .
7 6 f�( l�n r�( 'f� Pail f`�lc ,�( 02 ft. ft. 20
Physical Address,City,and Zip ft. ft.
21.RE114ARI{S ,J°. ii++i" "•
�L•CSSI ""G Ur'I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,
tone
�lat/longis sufficient) 22.Certifrca
�
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCettified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)u•as(were)construcred in accordance widr
7.Is this a repair to an existing well: ❑Yes or ©No ISA NCAC 02C,0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Il'this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the rgell owner.
repair ender#21 remarks section or on the back of this form.
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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / �' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdierent(example-3@200'and 1@100)
10.Static water level below top of casing: 2 lc) (ft) 24s. For All Wells: Original form to Division of Water Resources (DWR),
If ureter level is above casing,use"+" , Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Iniection Wells:Copy to DWR;Underground injection Control(rUC)
l 1.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing(over 100 000 GPD: Copy to DWR,CCPCUA
Q Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) [J Method of test:
HTH 1 lb.
13b.Disinfection type: Amount:
l
Form GW I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018