GW1-2022-03487_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 DESCRIPTION
3441 A 70 ft.
7 S ft. 3 (I ".
NC Well Contractor Certification Number /d R ils ft. 7 `!4 M
15.OUTER CASING.for multi-cas led wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAlit TER THICKNESS MATERIAL
Company Name /e s ft. 1,10.s R. In. •/ r 41
-
16.INNER CASING OR TUBING(geothermal closed-looul
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I aATERIAL
List all applicable well construction permits i.e.UIC,County,Slate,Variance,etc.) R.. ft. is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
FROM TO DUMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public R. R. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) R R In
❑hndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rr1 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT—
Non-Water Supply Well: O ft. d tt. pT-QN tT
❑Monitoring ❑Recovery M ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicableFROM TO I MATERIAL I RNIPLArr.MENT METHOD
❑Aquiver Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary),
❑Geotltennal(Heating/Cooling Retum ❑Other(ex lain under tE21 Remarks FROM TO DESCRIPTION color,hardness soillrock a rain size etc.
� ft. ft. a I o/ /_
4.Date Well(s)Completed: W-14129 Well ID# ft S 1" S&�D Z
/5aa..AWellll Location: /� d �f�''� ft 3as' it
I 'KAN FG / *FA i fi ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
73 ett iDF /V0ARCE ft. ft. 7 �..1;7 i i
Physical Address,City,anddip (oN ft. ft. 7
.N Zl:REMARKS MAR
County Parcel Identification No.(P[N)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laQt/long�is(sufiicient) `� Q �J 22.Certill, t'
✓ ✓� 1��( N 6 K, 2 I 1 � 1 W Z l O Z2-
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature ofCer ified Well Contractor Date
By signing this form,I hereby certify that the well(s)i as(were)constructed in accordance wuh
7.Is this a repair to an existing well: ❑Yes or LINO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a copy
If this is a repair,f ll out knonrn ive//construction information and explain the nature of the of this record has been provided to tire welt owner.
repair under 921 remarks section or on the back ofthis forn.
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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: t
24.SUBMITTAL INSTRUCTIONS
4.Total well depth below land surface:._ � (n•)
For multiple wells list all depths ifdoerent(example-3@200'and2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: do (ft) 249. For All Wells: Original form to Division of Water Resources (DWR),
Ijirater level is above 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(NC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producingover 100,000 GPD:Copy to DWR,CCPCUA
(BP ) Method of test:
13a.Yield m /O Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources 'k Revised 6-6-2018
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