GW1-2022-03492_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips MWATERZONES
Well Contractor Name FROM TO I DESCRIPTION
3441 A rL 6 e. b /?
NC Well Contractor Certification Number
IS..OUTER CASING for mul&-c ed wells OR LINER if a licsble
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
.L I i is - r '_U�l�
Company Name z 1T _
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit H: FROM TO DLOIETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R• n• in
3.Well Use(check well use): ft. It. in
Water Supply Well: 17.SCREEN,
FROM w TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural ❑Municipal/Public ft fL in.
❑Geothermal(Heating/Cooling Supply) )(Residential Water Supply(single) tt. ft In
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bTI ation - .❑Wells>100,000 GPD FROM I TO M TERW, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. ft. d f
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑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 soft/rock rain size etc.
9/ rt. 5 rL
4.Date Well(s)Completed: /-Z v-Z Well ID# n• C ft. C��
5a. /Well Location- ' I ft. S ft.
ft. ft.
Facility/Owner Na/ 5 w lKm1e (' //- Facility ID#(if applicable) ft. ft.
V13 ^Uty `� 1-6l r ,j C_ ft. ft.
Physical Address,City,and
/Zip d S� ft. ft. "
y k ndtr(l/C 21:REMARKS
Coun Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]atttlong is sufficient) ee�� (( 22.Certifies
-3 0
24 -2
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8N0 I5A NCAC 01C.0100 or 15A NCAC 01C.0100{yell 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 ojthis 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: t S (�/ J! 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdijrerent(example-3(200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6 (B•) 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 Wells:Copy tolDWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su ! and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental healt department of the county where installed
FOR WATER SUPPLY 7ELLS ONLY: 24d.For Water Wells -ducin over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) y Method of test: Blow Permit Program,1611 MSC,Raleig,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