GW1-2022-07758_Well Construction - GW1_20220819

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A
y It. ,' %
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LER if applicable)
NW Poole Well and Pump Company FROM TO DIAMETER THIINCKNESS I MATERIAL
Company Name A +/ ft. ,O Sft. !' In. s� D awi'e.
i p��, $_ ,,��` itc C'go3q o� 16.INNER CASING OR TUBIN (geothermal closed-loop)
2.Well Construction Permit N: UP� �! J t`1 FROM To DIAMETER THICKNESS MATERIAL
[JT1 all applicable well construction permits t'te.UIC,Cbunty,State.Variance,etc.) in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
idListrial/Comm FROMercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM I TO 11IATE EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft. 10 ft. Utz oe
❑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 10.DRILLING LOG attach additional sheets If necessary)
FROM I TO DESCRIPTION color hardness,soll/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 RemHtLl
10 ft. tt. --,,op f`L
4.Date Well(s)Completed: LP(' 2 Z Well ID# tt. '0 tt.
5a.Well Location: O ft. 6 ft, rLq�
S -K 1P 0 Peoy Neyer��lc�d- ft. ft.
41/
Faciiii(y//Ownner Name Facility ID#(ifopplicable) 1 ft. ft.
'7 11 IV',,I&rA A,11 f R-Jt bf1)e e_72.r1Vr �G' ft. ft.
Physical Address,City,and ZipCr"�oor NG Oq Js 2 Z ft. ft.
21.REMARKS t.
9(salt fJ r -'.
ounty ParcelIdentificadon No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` Pl nn'
(if wellfield,one]at/long is sufficient) �/ , 22.Certificat' D%AV.�iB0'G
C L��LO t Q,C - N h Y 00�h t t �QL ,�'t W t C/' 2
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)consir acted in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 fie//Construction Standards and that a copy
It this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells(laving the same You may use the back of this page to provide additional well construction into
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -++ 5 (ft.) Submit this GW-1 within 30 days of well completion per the following:
Far nudliple wells list all depths lfdii ferent(example-3@200'and 2@100)
Z yt 24a. For All Wells: Original form to Division of Water Resources (D'WR),
ft
10.Static water level below top of casing: U (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1J'water level is above casing,use"+'
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(fUC)
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 WELLSONLY: 24d.For Water Wells roducin over 100,000 GPD: Copy to DWR,CCPCUA
13a.field(gpm) I/ Z Method or test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
HTH 1 lb.
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8
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