GW1-2022-03497_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: *'
1.Well Contractor Information:
Landon Phillips 14.wATERZONES
Well Contactor Name FROM TO DESCRIPTION
3441 A 6 ft. ` rt. in
ft. ft.
NC Well Contractor Certification Number
NW Poole Well and Pump Company 15.OUTERCASING Cormulti-cased wells OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERL.AL`
ft. Gs'I)
Company Name + �C
.16.INNER CASING OR TUBING eothermal closed-loot))
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. I ft. in.
❑Geothermal(Heating/Cooling Supply) qKide.tial Water Supply(single) ft. I ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
❑irri ation ❑Wells>100,000 GPD FROM TO D EMP EMENT METHOD&AMOUNT
Non-Water Supply Well: ft 2 it. �� v�—
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK ifa licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO DATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION color,hardness,soil rock a rain size etc.
❑Other(explain under#21 Remarks Oft rt.
4.Date Weil(s)Completed:L
p 2/ C � a�
Well ID# it. tt.
5a./Well Location: /L tt. cits ft.
ft. ft. i' o
Facility/Owner Name / / Facility ID#(ifappplicable) ft ft.
[ f,� �trri�C 1`r&, "'-Cf `Ln///"/c— ft ft _c..-'
Physical Address,City,and Zi e� ft. ft. C
J 2L REMARKS
ao U Ric
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iflvell field,one lat/long is sufficient) 22.Certiftcat'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCed fled Well Contractor ` Date
By signing this form,I hereby certtfy that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well 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 011er.
repair wader#21 remarks section or on the back of this fornx
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 dweils (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r 9.Total well depth below land surface: cI!� (ft,) 24.SUBMITTAL INSTRUCTIONS:
For multiple spells list all depths ifderer,t(example-3(�00'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z (n) 24a. For All Wells: Original form jto Division of Water Resources (DWR),
If,vater level is above casing,use"+y Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ICJ (in,) 24b.For I>llectiog Wells:Copy to DWR,Underground Injection Control(ItJC)
Rota Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method, Rotary 24c.For Water Su I and O en-Loo 'Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) _county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program;1611 MSC,Raleig ,NC,27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Fora GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018