GW1-2022-03456_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRH'TION
3441 A rc. ` 5rt.
rt. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased'wells OR LINER if a licable
NW Poole Well and Pump Company F DIAI,fETER r1HCKNESs
ROMTO MATERIAL
ft. (� ft in.
Company Name I I l t•(�o M�
q 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: fJ S /u/ FROM TO DIAMETER THICKNESS MATERIAL
List al/applicable well construction permits(Le.UIC,County,State,Variance,etc) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICIQVESS aATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft, ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FRO51 TO _MATERIAL EI11P CEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. ft. Ave
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT arETHOD
❑Aquifer Test ❑SlormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sbeets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRrPT10N color,hardness soWrock a rain size etc.
6 ft. d ft.
4.Date Well(s)Completed: -I D' Z I Well ID# ft. ft.
5a.Well Location: 3 ft. ft. t
Nat
ft. ft.
D P� C•it r-k t- J GIB �
F cili//ty/Ownne�er Name n Facility ID#(if applicable) ft. ft.
t7/ /,V(A z f f C+�c C i f� S bOrd i1/C of 7 /Z ft. ft. ''
Physical Address,City,and Zip ft. ft.
C I (n f/16.x1 21;REbIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I it t•;
(if well field,one fat/long is sufficient)
n 22.Certiiteaf
�
3S OL � c�_W Z I G Z
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Dat
By signing this form,I hereby certyy that the ivell(s)was(were)cosirueted in accordance it
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 well Cashvction Standards and that a copy
Ifthis is a repair,fill out known well construction h formation and explain the nature ofthe ofthis record has been provided to the well onver.
repair under#21 renmrks section or on the back of this form.
23.Site diagram or additional well details:
8.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: 1
S© 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdii ferenr(example-3@200'andd 2@I00') Submit this GW-1 within 30 days or'Well completion per the following:
10.Static Water level below top of casing: 20 (ft.) 24a. For All Wells: Original form ',to Division of Water Resources (DWR),
If water level is aboPe casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:(i.e.auger,rotary,cable,direct push,etc.) 24c.For r Wate Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells aroducine over 100 0"GPD• Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test- BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1 611
13b.Disinfection HTH 1 lb.
tyPe• Amount:
Form GW-l North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

LWake fount.WGIi��R pal Repo�fi .%fWelihead ins action re
quest
equest
LSIte
County Well Repair permit#
Cj Owner:
dress: ner.contact phone number:
Vi
CIty: / ZP Code: r..
Well type: Well tag located?
�' Casing depth:
�51 /
Static level:
Water zones: ` WRII yield:
l ay
Camera Inspebtlon7lill, Existing liner or screen?
Well depth:
Evidence of oi grout: Total depth of liner or screen:
Wellhead above grade?
o
Weird Well yield:
Water zones*:
— — Static level: <
Water zones:
Liner Installed?
�'— Liner depth from top of casing:
Screen Installed?
Depths of screened sections? �� f
Well hydro fractured?
Wellhead raised above grade?
lip
h
Contractor�fame
Tit NCWCCC .Certification number:
------------
f �
Signature of contr or' Date: f Z
Contractor phone number: � Z
Wake County well repair repOrt7/09ver.