GW1-2022-03496_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A 0 rt. 5 ft. I n�
ft. ft. U,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIM 7ER THICKNESS MATERIAL
ft.
Company Name t
3 /p 16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: 7 l/ FROM I TO I DIAMETER I THIC[INF.SS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,variance,etc) ft. ft. in.
3.Well Use(check well use): ft. f[. io•I
Water Supply Well: 17.SCREEN
PPY FROM TO DIAMETER SL1 TSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) `Residential Water Supply(single) ft. ft. in.
❑hldustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. 'Zo
ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: tr. 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 she;is if necessary)
❑Geothermal(Heating/Cooling Return) ma❑Other(explain under#21 Rerks) FROM tr TO DESTIONI color handnessulrock type, rain size,etc.)ft.
4.Date Well(s)Completed: 1.0-IZ 2- Well ID# ft,
t ft. /
51.Well ft.
ft.
ft. fr. i
1
Fac ity/Owner Name Facility ID#(if applicable) ft. ft. n
ft. fL
Physical Address,City,and Zip J 7�e�/ ft. ft. MAR
f O' / t7 21:REMARKS
Cowl Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifieat' .
I
N �5. 0 7 W .2 2
6.Is(are)the well(s):XPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby ceri�&that the the i(s)ivas(irere)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or XNo 15A NCAC 02C.0100 or 15A NCAC 02C.020 (Yell Construction Standards and that a copy
If this is a repair,fill out lounvn ivell construction information and explain the nature of the ofthis record has been provided to the hell om'er.
repair under#21 rentarld section or on the back of this form.
23.Site diagram or additional well de ils:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pi ovide 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: Q _ (ft.)
For multiple ivells list all depths ifdierenr(example-3 200'and 2@100� Submit this GW-1 within 30 days of w 11 completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,I Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter: (in.)
24b.For Injection Wells:Copy to D R ,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699,1636
12.Well construction method: Rotary 24c.For Water Supply and O en-Loo I Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department'f the county where installed
FOR WATER SUPPLY�ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Blow Permit Program,1611 MSC,Raleigh;NC 27699-1611
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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