GW1-2022-03550_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name f(L f � R. /� r�
3441 A U t.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cesediwc0s OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. �� 6c1✓.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
Z
2.Well Construction Permit 4: lnJ �SS /Cl - ' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits ri.e.U1C,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): tt. tt. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. tt. in
❑Geothenmal(Heating/Cooling Supply) AResidential Water Supply(single) ft. ft. in.
01r1dustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lffi ation ❑Wells>100,000 GPD FROM I TO ATERLIL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 7ej ft. �'
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETIIOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothernal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO- DESCRIPTION color hardness soiUrock a rain size etc.
7 ft. tr.
4.Date We0(s)Completed: G�-Z Well ID# /L tt. if-7
5.9.Well Location: 7 ft. o S
4 (/ L_ ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
WO SC,I'M J 6L-4 5 UJC - % t/J J OW 59".jy R. fr.
Physical Address,City,and Zip NC. d ft. ft.
C' -
21:REDIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
((iifivell field,ones]]aatt/lonng is sufficient) 1 •a 22.Certificat'
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6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of'Certified Well Contractor ` Date
By signing this form,]hereby cerq&that the icell(s)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the cell owner.
repair under#21 rentarls section or on the back ofihis form.
23.Site diagram or additional wellldetails:
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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft
For multiple hells list all depths ifdierent(example-3@200'annd)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 form to Division of Water Resources (DWR),
If water level is above casing,use"+r Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (c7 (in,) 24b.For Injection 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 Open-L'oop 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 Vi'FLS 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 27699-1611
13b.Disinfection type: f Il I I Amount: 1 lb.
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Fortu GW-i Notch Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-201.8
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