GW1-2022-06409_Well Construction - GW1_20220603

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips WATERZONES
FROM TO DESCm ION
Well Contractor Name
3441 A 170
"' "'
ft. ft.
NC Well Contractor Certification Number 15:OUTER'CASING for mulfl-cased wells OR LINER if a licabie
NW Poole Well and Pump Company FROM TO DIAM TER THICKNESS MATERIAL
ft. 11- in. I .(f C_I JI---(6
Company Name / r
�rW�OS w � 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: ' FROM TO DIAMETER TIHCKNESS MATERLAL
List all applicable well construction perudts(i.e.UIC,Coun),,State,Variance,etc.) ft. ft. iu.
3.Well Use(check,well use): ft. ft. Ia
Water Supply Well: FRO51 TO DIAMETER SLOT SIZE THICKNESS 71fATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. 11L
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Oh-ri ation ❑Wells>100,000 GPD FROM I TO ATERIAL E111P CE�SEN M T METHOD&AOUNT
Nou-Water Supply Well: ft. ft.
❑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 51ATERML EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sbeets if necessary)
❑Geothennal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
ft. ft. �4_r
4.Date Wells)Completed: ^��-Z Well ID# ft. ft- 4
5a.Well Location: ft. ed t. k
m� ft.
Facility/Owuer Name A ! Facility ID#(if applicable) ft ft. u
�C]N /W '� e ft. ft. k,,? ate �k
hysical Address,City,and Zip ft. ft.
21.REMARKS t
County Parcel Identification No.(PIN) e}o ri U _.;at v_��s� lii4-1
5b.Latitude and longitude in tie rees/minutes/secouds or decimal degrees: ` ter"
(if well field,one fat/long is sufficient) � �� �� 22.Certifica
? 0)CP 0 N W ' W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
c By signing this form,I hereby ceri fy that the ivell(s)was )i,ere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©ND ISANCAC 01C.0100 or 15ANCAC 02C.0100 Well Construction Standards and drat a copy
{(this is a repair,fill out known well construction h formation and explain the nature ofthe ofthis record has been provided to the ivell owner.
repair under#21 remarks section or of the back of this forn.
23.Site diagram or additional well 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: 1 e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface.: (ft.) Submit this GW-1 within 30 days of well completion per the following:
Fo•nnihiple wells list all depths ifdierent(example-3 a200'and 1@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ZO (ft.). Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1fu•ater level is above casing,use
1.1.Borehole diameter: 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return We" :
Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health departtnent of the county where installed
FOR WATER SUPPLY ELLS ONLY: 24d.For Water Wells prod ucin¢over 100,000 GPD: Copy to DWR,CCPCUA
BIOW Permit Program,1611 MSC,Raleigh,NC 27699-]61 I
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018