GW1-2022-03498_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 l 0 ft. 1 CIS ft. 9' n1
NC Well Contractor Certification Number �(J fL I ft S I
15.OUTER CASING for multi-cased US)OR LINER if a licabte
NW Poole Well and Pump Company FRO51 TO DAMETER TIIICIQVE55 MATERIAL
Company Name f ft. 1 It. I !in.
16,INNER CASING OR TUBING etither al closed-loop)
2.Weli Construction Permit#: I �.�b � FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permlis(l.e.07C,County,State,Variance,etc.) fL 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. ft in.
❑Geothermal(Heating/Cooling Supply) ,oesidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bTI ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z(' ft. U.v�
❑Monitoring ❑Recovery ft. ft.
Injection Well: tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
'19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I 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) ❑ether(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock type,grain siu etc.
�\ C ft Z ft. 2 P /
4.Date Well(s)Completed: V r�-J' 2 Well EM 2 ft. -7 'L C/
51.We I Location: 7 ft, Z o 5 ft
Ut r C c-u`he r�y ft. ft
Facility/Owwner Name` r Facility lD#(if applicable) ft. ft.
ft ft
Physical Ads,City,and Zi ft. ft.
J V t l S 21.REMARKS I_ 6, is t r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if wee�wlll •/onnee"/]attt/llloo��ngg is.sufficient) //I/{/�(t/ j/J 22.Cerlifrcat (i ,Afield,
N _ I V V�I W {I, F F Vf�f`\(-' `t r�i 11•.
.l
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forin,I hereby certify that the tvell(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.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 io the well ouster.
repair under 921 remarks section or on the back olthis fonn.
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 I GW-1 is needed. Indicate TOTAL NUMBER of'wells (add'See Ovice in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: zb� (ft.)
For multiple wells list all depdrs ifdierent(example-3 tt 00''a7nd 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2V (n) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If u•ater level is above casing,use'+` Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWI,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
24c.For Water Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health eparnnent of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Droducin2 over 100.000 GPD• Copy to DWR,CCPCUA
Method of test:
m 13a.Yield
(gp ) Blow Permit Program,1611 MSC,Raleigh,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