GW1-2022-03495_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips N14. ATERZONES
Well Contractor Name TO DESCRIPTION I3441 A ft. It, Z -.
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
in. ,J��/
Company Name ✓ - l v O G`(J!
3� ]�/ 16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: 0/ ( FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits,(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.well Use(check well use): fL m in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SL T SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public t7, ft. in.
❑Geothennal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrl ation ❑Wells>100,000 GPD FRO51 TO MATERIAL ! EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O tr. �-,,,ft. i i
❑Monitoring ❑Recove
rY ft. ft. �
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable !
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION 'olor,hardness soil rock type,grain size etc.
ft. Z ft. I ��r
4.Date Well(s)Completed: Well ID# tt. - tt. C_iLLi V
5a.Well Location:
OR,"ft B(I(dw-'I) ft. ft
Facility/Owner Name / Facility ID#(if applicable) ft. ft.
Ct-s y ill� �e V✓�(SU.� /!J ft. rL
Physical�Address,City,and Zip a -25 ft. ft.
1 f(r el t/i i L�( 21:REMARKS
Coun Parcel Identification No.(PIN)
J •f• ,t .l 1,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i£well field,one Iat/long i s sufficient)
�U�. 22.Certificaf
o N — •73,
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the I vell'I)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15ANCAC 01C.0100 at-ISANCAC 01C.0200!Veil Construction Standards and that a copy
if this is a repair,fill out known ivell construction information and explain the nature of the ofthis record has been provided to the well owne,.
repair under#11 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',vide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may lso attach additional pages if necessary.
drilled: 1 �
24.SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface: 0' (ft) Submit this GW1 within 30 days of well!completion per the following:
For mu w ltiple ells list all depthsifdi,/ferent(example-3@200'and 2@I00) um s - w n Y P P g:
10.Static water level below top of casing: 26 (ft. 24a. For All Wells: Original form to ivision of Water Resources (DWR),
Ifwater level is above casing,use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: _(in,) 24b.For Iniectiog Wells:Copy to D, Underground Injection Control(IUC)
Rota Program,1636 MSC,Raleigh,NC 27699-1b M
12.Well construction method: ry 24c.For Water Supply and O en-L00 eothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department oft he county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 10 000 GPD:Copy to DWR,CCPCUA
13a.Yield m Z Blow Permit Program,1611 MSC,Raleigh,NC 2 699-1611
(gP ) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
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Forte GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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