GW1-2022-03490_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 w
3441 A rt. �J rt. ^-
NC Well Contractor Certification Number Ana
15.OUTER CASING(for ulti-cased; s OR LINER if so licable
NW Poole Weil and Pump Company FROM m
TO DIAMETER THICKNESS MATERIAL
ft-
Company 1 in. � V••
Company Name t
16.INNER CASING.OR TUBING(geothermal closed•loo
2.Well Construction Permit#: J VQ FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Pariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt: ft. ;a
❑Geothermal(Heating/Cooling Supply) `Residential Water Supply(single) ft. ft. in.
❑bidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl atioll ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMO T
Nou-Water Supply Well: D 6 .
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applichble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. n.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLWG LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color hardness soil/rook a rain size etc.
❑Geothermal(Heating/Cooling Retum ❑Other,ex lain under#21 Remarks D ft. Z ft. fpe
4.Date Well(s)Completed: 41uh Well ID# 2 ft. 3s ft. tt W
5a.Well Location: s' S ft. f ft.
i
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
a a
Physical Address,City,and 2• ft. tt.
2 T U,F! `Fg G':_I 2L REMARKS
MAR 202?
County Parcel Identification No.(PIN) S � /►IS u na..9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) tfrry�^ 22.Certifica'
N W
1 T- r. ? =L
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Da
fe
By signing this form,/hereby certify that the tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or ISANCAC 01C,.0100 ir'ell Construction Standards and that a copy
If this is a repair,fill out brown 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'detalls:
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 M $0 (ft.
For multiple wells list all depths ifdierent(example-3@200'and 1@100) ) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: Z (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Iftrater level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
M 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: ��(in.) Program,1636 MSC,Raleigh,NC 27699-1636
2.Well construction method: Rotary
12.auger,rotary, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
,cable,direct push,etc.) county environmental heal department of a county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing oi'er 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0 Method of test: Blow Permit Program,1611 MSC,Raleigh;NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 lb. I
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources y Revised 6-6-2018
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