GW1-2022-03485_Well Construction - GW1_20220322

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 �j It. p�fr. ems 1 /y\
/ It. c-/ ft. /G 6 �
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft ft � in.
Company Name
3 'w,.�� 16.INNER CASING OR TUBING eothermat closed-loo
2.Well Construction Permit#: —30 FROM TO DIAMETER I THICKNESS FMATERIAL
List all applicable well construction permits(i.e.IIIC,County,State,Variance,etc.) ft. -76
ft in. �{�r
3.Well Use(check well use): ft. et 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 esidential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
tr. tr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I 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 necessa'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness sou/mck type,grain size etc
ft 7. ft. S� - c
4.Date Well(s)Completed: 'l Z z( Well ID# tr.
ft. ft.Sa.Well Location:
SL�TF
Tv(I L M o ft. fr.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Zebulyn �� ft ft
Physical Address,City,and Zip 2•7517 ft. ft.
JE�/C''i� o 21.REMARKS
—�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one iat/long is sufficient) Q� 22.Certificat'
�/
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor " Date
By signing this form,I hereby cert fy that the wells) vas(were)constructed in accordance with
7.IS this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 under#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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: )) l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � /�> (ft.)
For multiple wells list all depths ifdi ftrent(example-3@200'and;@100) Submit this GW-1 within 30 days of well completion per the following:
2( 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above cast Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ng '
24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
I1.Borehole diameter: ,use' (in.) Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Supply and ODen-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 SUPPL}'WELLS ONLY: 24d.For Water Wells Droducin¢over 100.000 GPD:Copy to DWI,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 6-6-2018
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