GW1-2022-03494_Well Construction - GW1_20220322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441A 5".
ft. ft.
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
Company Name "' S5 ft' ?""11 -r G(/'
16.INNER CASINNG OR TUBING eother al closed-Oloo J C
2.Well Construction Permit th •.] C/(J / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. I in.�
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER i SL(T SIZE I THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. ; �"1 ft. MUM 0)r_I
❑Monitoring ❑Recovery ft. V ft. J
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional wheel s if necessary)
❑Geothermal(Heating/Cooling Return) TO DESCRIPTION olor,hardness soillmck rain sin etc.
) /❑Other(explain under#21 Remarks) ft ft.
4,Date Wells)Completed: 1(7�!`�Z 1 Well ID# ft. rr.
5a.Well Lo,�c.,a,/tion: ft. O ft.
& ! �GfGt�t ft. ft.
Facility/Owner Name Facility 1Dtl(if applicable) ft. ft.
9y y Cis�r�-«� <� y��15v,t,(� .tip ft ft.
Physical Address City,and Zip a SCI ft. ft.
21:REMARKS �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f
(ifwell field,one lat/long issufficient) 22.Certifrcat'
3Vl • �(oo(oVN W
-/72
Signature of Certified Well Contractor Date
6.Is are the 1 �Is(are) c wel(s). ®Permanent or ❑Temporary -,
By signing this form,I hereby certify that the jwell )was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15ANCAC 01C.0100 or 15ANCAC 02C.0200 lVell Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well ownel.
repair under 921 remarks section or on the back ofthis form.
23.Site diagram or additional well detail :
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'pro ide 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 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓0 J (fL)
For multiple wells list all depths ifdoerent(example-3@200''a/annd 2@100) Submit this GW-1 within 30 days of wellicompletion per the following:
10.Static water level below top of casing: V (ft.) 24a. For All Wells: Original form to Division of Water Resources (DR),
Ifirater level is above casing,use"+ Information Processing Unit,1617 MSC,R leigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,,I Underground Injection Control(lUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-16 36
12.Well construction method: 24c.For Water Supply and O en-Lolo eothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department ot1 to county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 16,000 GPD:Copy to DWR,CCPCUA
Blow Permit Program,1011 MSC,Raleigh,NC 2 699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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