GW1-2022-03543_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-11 For Intemai Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO^ DESCRIPTION
Ai
Well Contractor Name 'U ft' a5 ft
3441 A 9 ft
NC Well C.mmetm,Certification Number 15.OUTER CASING for multi-cased wells OR LINER its licable
NW Poole Well and Pump Company FROM ft TO ft. DIAMETER la THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING eothernaal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
t^I,�
2.Well Construction Permit#: `�f tt. ft. in.
Lut all applicable irell construction permits lice.UIC,County,Slate,Variance,etc.) in.
ft. ft.
3.Well Use(check well use): 17.SCREEN.
FROM . TO DIAMETER !. SLOT SIZE THICKNESS MATERIAL
Water Supply Well: tt. in.,
❑Agricultural ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply)
vs,esidential Water Supply(single) g,
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lri ation ❑Wells>100000GPD ft ft.
Non-Water Supply Well: ft i
❑Monitoring
❑Recovery ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Salim Barrier FROM TO MATERIAL EMPLACEMENT METH
OD
❑Aquifer Storage and Recovery tY ft ft
❑Aquifer Test ❑Stormwater Drainage
ft.❑Experimental Technology
❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.FROM
LOG attach additional sheets if neceasa
FROM TO 1 DESCRLPTION color hardaeas aoiUrack a rain sin etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks O ft ft. r s L
4.Date Well(s)Completed: Z
� ft. ` ft
5a..Well Location-
/ S ft. ft
(
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
A66s See/tip Ro�u��- ft. ft. 2 2
Physical Address,City,and Zip 5 ( i�{7
21:REMARKS '
tVlbff� NG •:�� L:.; � � In
County Parcel Identification No.(PIN) `(11 i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certificat'
(if well field,one lat/long is sufficient)
N �.
Signature of Certified Well Contractor.
_
�— Date
6.Is(are)the well(s): (9Permanent or ❑Temporary
By signing this form,I hereby certify that the avell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200{Nell Construction Standards and that a copy
ojthis record has been provided to the hell ounner.
If this is a repair,fill out known suetl constructions information and explain the nature of the ;
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional will details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3(200'and%1000
24s. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: O'V Information Processing Unit,1617 MSC,Raleigh;NC 27699-1617
If water level is above casing,use"+"
24b.For 1aiection Wells:Copyj to.DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water 5upplY and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
E
SUPPLY WELLS ONLY: 24d.For Water Welts roducin over too 000 GPD:Copy to DWR,CCPCUA
BloW Permit Program,1611 MSC,Raleig ,NC 27699-1611
m) V Method of test:HTH 1 Ib.
ion type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018