GW1-2022-03458_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal.Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 'O C CAM
M ft.
3441 A J � M
rc. ra
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
t ft. t_/ ft. in. r /G
Company Name O
Q� / 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: !// 6 FROM I TO I DIAMETER I THICKNESS MATERIAL
Lint all applicable well construction permits(i.e.'UIC,County,State,Variance,etc.) ft. ft in.
3.Wei Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑krl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2 C)ft. O U�/
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑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 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUrock type,grain size etc.
J ` U ft. fL Sv
4.Date Well(s)Completed: / 7 2 1 Well ID# ft,
36 ft.
5a.Well Location: ft. ft. '�-
?Lt.(-J A Nl. 4-4 ft. ft.
Facility/Owner Name t Facility ID#(if appbcable) ft. ft.
(� 2 12 trn 0 n lv,L1,1L ft.
Physical Address,Ci and Zip a 7 55�( ft. ft.
C h Gt f 4 nj 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ji 91
((iifwell field,one IatQIon-g its sufficient) p (mac 22.Certlfleat'
IS �'C.�1 N -4_ V I .�� e W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair tender#21 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 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: I tJ� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.
For multiple wells list all depths it dii ferent(example-3@200''anted 2@100') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �l V (ft.) 24a- For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Welts:Copy to 15WR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i
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 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018