GW1-2022-03488_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips lA.WATER ZONES
FROM ROM TO DESCRIPTION� ft coft. 'S
3441 A fI
w ft /r" `
NC Well Contractor Certification Number fL
NW Poole Well and Pump Company FR 511TERCTO formul8-METEvells OR LINERS licabie
FROM n DIAMETER THICKNESS MATERIAL
ft. R ft. Itt 'O
Company Name
16.INNER CASING OR TUBING 'eothetmal cloled-too
2.Well Construction Permit#: FROM TO DLAMETER I THICKNESS MATERIAL
List all applicable irel/construction permits(r.e.UIC,County,State,Variance,etc.) D- ft. In.
3.Well Use(check well use): ft. ft. in.
17,SCREEN
Water Supply Weil: FROM TO DL►METEA I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural `$Municipal/Public tt. 03 rL If io Q I *;
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft. io
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO - AIATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3� tt. F1VTr/7
❑Monitoring ❑Recovery ft. ft. i
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EAtPLACEAIENT METHOD
❑Aquifer Test ❑Stormwater Drainage "' /OS n' 3
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geotltennal(Heating/Cooling Return ❑Other ex lain under#21 Remarks FROM TO DESCRIPTION color hardness sou/mck a rain size etc.
G ft. A ft. TOP So I
4.Date Well(s)Completed: Well ID# ft. ' R.
5a.Well Location: � � � ft. ()
TtM RC K�GG ft. ft.
Facility/Owner Name Facility[D#(if applicable) ft. ft.
,6AAxTa/✓ 8 Avis, a.-- tl"�nMs,1A,..� u. ft. IR
Physical Address,City,and Zip ft. ft.
CAPAL IN 21.RE51ARKS
County •` Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer/t�ifieat'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that llte ivell(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No I SA NCAC 01C.0100 or 15A NCAC 02C.0100 1Vell Construction Standards and that a copy
If 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 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).Y.ou may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /0_ (R') per Submit this GW-1 within 30 days of well completion the following:
1--or multiplewells list all depths fdoerent(example-3@200'tmd 1@100') y. P P g:
10.Static water level below top of casing' 'a tJ (R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifu•oter level is above casing,use"+" i
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy fo DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.1Yell construction method:
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotar
y,cable,direct push,etc.) county environmental health department of the county where installed
FOR RATER SUPPLY WELLS ONLY: 24d.For Water Wells produchii over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m �U Method of test: Blow Penn rt Program,1611 MSC,Raleigh,NC 27699-16 1
(gP )
13b.Disinfection type: HTH Amount: 1 lb. kk
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6.2018