GW1-2022-03504_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1:Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRn'TION
We1lContractorName OfL s`s ft. S'!C
3441 A y I
NC Well Contractor Certification Number vo ft /� ft t7l
15.OUTER CASING for multi-cased we OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name
. It. o ft. I. in. • AW
/!
16.INNER CASING OR TUBING eothermat closed-loop)
000 4�Z.Well Construction Permit#: FROM TO 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): ft ft. in.
Water Supply Weli: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNEss MATERIAL
❑Agricultural ❑MunicipaUPublic Q ft. f 4 in. 010
G v�
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. tt. in,
❑hrdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑liTI ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft. Q ft. TG
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Batrier FROM TO 51ATERUL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage OQ ft sn• Rot:'
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLWG LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM TO DESCRIPTION color,hardness soilinck type,grain size eta)
I% ft. 01 ft. 7o sO�L
4.Date Welt(s)Completed: Well ID# f, tt s D
5a.Well Location:
ft. O • ft' CJ 17
APT�) 41 fN lto"I'S ft. IL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
H' Cl A� fL ft. t.
o
Physical Address,City,and Zipt t�p ft. ft
2I.REMARKS MAR 2 2 -
County Ti Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
375. 9
� G� -7 Q' +f' 22.Certificat• rt.r�•,��.• ry y
75. o(e l N �O .�T�1� W �.�
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCettified Well Contractor ` Date
By signing this form,l hereby certify thai'die well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or ANo 15A NCAC 02C.0100 or ISA NCAC 02C.0100!Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain lire nature of the of thls record has been provided to the smell onmer.
repair under#21 remarks section or on die back of this form.
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 of welts (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: • (ft.)
For multiple wells list all depths ifd6Terent(example-3@20 nd 2@100) Submit this GW-i within 30 days of well completion per the following:
10.Static water level below top of easing: a (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If,rorer level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I
24c.For Water Supply and Open-Liiop 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 Water WeI1s producing,over 100,000 GPD100,000 GPD:Copy to DWR,CCPCUA
(gp ) Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
m 13a.Yield Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018