GW1-2022-06400_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 FRO51 TO DESCRIE'TION
3441 A rt rt.
ft. ft.
NC Well Contractor Certification Number 15.OUPER CASING for multi-cased wells OR LINER if applicable)
NW Poole Well and Pump Company FROM TO DIAMETER TIICKNESS MATERIAL
ft.
S ft. iu. -I W(V j�C,�,
LA
Company Name
W- o s9a 79-zo2 R ER CASI OR TUBING n.mnl closed-loop)_
Well Construction Permit If: FROM TO DLt11fETER ER in.
THICKNESS MATERIAL
Litt all applicable well construction perm is(i.e.UIC,County,State,Variance,etc.) ft. ft. v
3.Well Use(check well use): tt' ft' in.
Rater Supply Well: :11 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricµltural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Ij�Residential Water Supply(single) ft ft. in,
❑hidustrial/Commercial /❑`Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIA EMPLA NIENT METHOD&AMOUNT
Non-Water Supply Well: ft. It.
❑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 I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
FROM TO DESCRIPTION color,hardness soilfrock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft.' ft.
4.Date Well(s)Completed: Well IDtf ft.
r
5a.Well Lotc1ation: I j
Id
Facility/OwwiterName r F acili #(fpliabl ft. f.
e ft.
/ rp A. i
ft-
PhysicalAddress,Ci
// and ft. ff n T?^.'-'
[/1♦ / 2L RE51ARIfS
r{fi:.7vttI FUN 1UN ir'PilUlrt- P- r: l
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certifier' ?
.3FJ C'�dOI N — t�:oDa 3 W
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 well(s)was(it-ere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
IJ'this is a repair,fill out known trell construction information mid explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Ge.oprobe/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 Oven in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) -
Fo•multiple wells list all depths ifdWerent(example-3@200'and 2@100) Submit this GW 1 within 30 days of well completion per the following:
�{ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: U (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
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 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 G Copy to DR,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 2 GP W
7699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018