GW1-2022-03503_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM 0 DESCRIPTION
well Contractor Name 1 ft.
3441 A
ft. f4
NC Well Contractor Certification Number 15.OttTER CASING for multi-cased wells OR LINER if appl[table)
NW Poole Well and Pump Company FROM I TO DIAMETER I llucuq§ MATTERI/AL{
ft. i✓ ft.
Company Name 16.INNER CASING R TUBING eotherwal clo3ed400
2.Well Construction Permit#: FROM TO - DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc) ft. ft.
3.Well Use(check well use): I, ft. m
Water Supply Well: 17:SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MIATERLIL
❑Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) toesidential
esidential Water Supply(single) ft. ft. fti
❑Industrial/Commercial Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO IATER1AL EMPL EMSENT METHOD&AMOUNT
Non-Water Supply Well: Ott.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
tl. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL E51PLACEMENTMETHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return ❑OOmer(explain under#21 Remarks FROMTO DESCRIPTION color,hardness soittrock 'e ruin size etc.
4.Dale Well(s)Conmpleted: -22 Well ID# tt tt. (,L.
5a.W it Location: O ft. tt. /.O
ft.
Facili /Owner Name Facility ID#(if applicable) ft ft li i r '
3 f? l i hCP - /`� L ft. ft.
Physical Address,City,and Zip 5 ft. ft.
/ 'it_C 11 REMARKS
AVV1iJ
County Parcel Identification No.(PIN) � ,� ,•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablong is sufficient) 22,Certiflea'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor _ ` Date
By signing this form,l hereby certify that the svell(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 Well Construction Standards and that a copy
Ifthis is a repair,fill out knou-ir well construction information and explain the nature ofthe ofdris record has been provided to the ivell owner.
repair under 921 remarks section or on lire back of this form.
23.Site diagram or additional well'details:
3.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 of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9..TotaI well depth below land surface: 5` (ft.) Submit this GW-1 within 30 days of well completion per the following:
For•mnitiple wells list all depths ifd�erent(example-3(�00'arrd 1@100)
10.Static water level below lop of casing: 0 (B) 24a. For All Wells: Original form to Division of Water Resources (DWR),
(swore,•level at er l e casing,use' Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
is 11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Opeu-Loop 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 producing,over 100,000 GPD:Copy to DWR,CCPCUA
13a.field(gpm) V Method of test: Blow, Permit Program,1611 MSC,Raleigh,NC 27699-16 1
13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6.6-2018
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