GW1-2022-06752_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 1 3441 A �� ft 17o tt /,1 �An
t
ft. Ift.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROai TO DIAMETER THICKNESS MATERIAL
f. ft. in. . '�f
Company Name /`` // 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: 3LL373 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable irell construction permits(i.e.UIC,County,State,Parlance,etc.) ft. ft. in.
3.Well Use(check well use): ft. I If. Ia
Rater Supply Well: 17.SCREEN
FROM TO DIAIFIETER SLOTSIZE THICKNESS MATERLIL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tt. in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lfrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft. ft. DLi f tJ
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK [f applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geolhennal(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 sorUrock type,grain size etc.)
tt. ft. U
4.Date Well(s)Completed: ` '>' Z Well ID# tt. ft. C. (/
5a.Well Location!: ft. ft. (G n tt C
C3C C040/n hams ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1003 3`5 W 1',AJ PAce. MAN' I lk yc AW d ft. ft.
Physical�Ayddress,City,and Zip ft. ft.
V f&n U t ? 21.REMARKS
County 1 Parcel Identification No.(PIN) 202,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' .,&TPmac. rtltl
(if wellfield,one fat/long is sufficient) /� _ --/� 22.Certifies' A-ef�t�q � � �''PY`SfiN'+I \I
.._,/Yr o D5l� 1 N �'`I S( C�tJ `1 G t_ov i .�r,i
r
1/ Q� W - 2 .
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Dat
et
By signing this fornn,I hereby certify that the irell(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No ISA NCAC 01C.0100 or ISA NCAC 01C.0100 lVell Connsinicrion Standards and that a cop),
finis is a repair,fill out known well construction Information and explain the nature ofthe ofthis record has been provided to the i ell owner.
repair under P21 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-I 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
r
9.Total well depth below land surface: �Q- (ft.) Submit this GW-I within 30 days of well completion per the following:
for multiple wells list all depths ifeli ferent(example-3@200'and 1@I00)
fifi 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
ifcraier level is above casing,use"+"
11.Borehole diameter: It (iD.) 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 Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental ealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a,field(gpm) Method of test:
Blow Permit Program,161 I MSC,Raleigh,NC 27699-1611
� �
HTH 1 lb.
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018