GW1-2022-03507_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(G W-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A s ft. 70 ft. �s
NC Well Contractor Certification Number 8o ft d S ft f e'1,..
15.OUTER CASING for multi-cased'vells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name +I.7 ft. 5KS• ft. i "' At GAS.✓ Mom,
O� 1 16.INNER CASING OR TUBING eothermal closed-loop) Y
2.Well Construction Permit th ' �2� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft. I in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. �$ ft. I.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial Residential Water Supply(shared) 18.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. O ft. /�pMt
❑Monitoring ❑Recovery ft. ft.
Injection Well:
tr. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. 8^ ft. s CRAVE {�
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soilfrock type,grain size etc.
^ O ft. ft. 1 L
4.Date Well(s)Completed: Z S Of Well ID# ft' IL I ft. S t
Sa.Well Location:
)%AFC Ir-
f` SLATa.
/VN R/C ft. ft
Facility/Owner Name Facility ID#(if applicable) ft ft. _
ft ft � �� 'r • ,r
Physical Address,City,and Zip s t ft. ft. ,
S /, 21.REMARKS C
County /7 Parcel Identification No.(PIN) hfeb fly5 Y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ., ',T;C:-1 'U ``Z;:,`' ,11.I
(if well field,one fat/long is sufficient) 22.Certifrcat'
zsc'3 1 ,N
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor I Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 2INo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Comtruction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of fire of this record has been provided to the well owner.
repair under#21 remarks section or on the 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You'may also attach additional pages if necessary.
drilled: 24.SUB51IT717AL INSTRUCI IONS
9.Total well depth below land surface: (ft.)
Far multiple wel/s list all depths ifdierew(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original forme to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27 f
(i.e.anger,rotary,cable,direct push,etc.) 699-1636
12.Well construction method: 24c.For Water Supply and ODen-Loop Geothermal Return Wells:Copy to the
county envtronmenlal 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.Yield(gpm) �� Method of test• Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018