GW1-2022-03551_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3441 A 110 ft. ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased r'vells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DtAIETER THtCK1VESS MATERIAL
rr 11. ! in. J� J
Company Name //t t • C'
16.INNER CASING.Oft TUBING eothermal closed-loo i
2.Well Construction Permit#: FROM To 1 DIAMETER I THICKNESS I 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 Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS M1IATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPL EMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. rt. v
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Ground%iater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if alicableFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sontrock type,grain sin etc.
] G ft. 2 rr.
4.Date Well(s)Completed: / Z 7`Z WeII 1D# ft. J, ft. 1 }/
5a.fell Location: ft. ft.
LLLT rt. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9�G 1 z .5t`',g d- (.4.1:1 Wit / ty,116 .SPrr M ft. ft. r, .
NLY City, p ft. fL
Physical Address, and Zip (f .130-5 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
��. ((�� �y,a` 22.Certificat' t�..��,
N W _
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date `,? _
By signing this form,I hereby certify that the irell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Nell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the ivellowner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Gcoprobe/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
Z ( 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: ) ((I,)
For multiple wells list all depths ifdoerent(example-3 2000'and 1@100') Submit this GW-1 within 30 days of,-.veil 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),
Ifu•ater 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.e.auger,rotary,cable,direct 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
t push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY ELLS ONLY: 24d.For Water Wells producing over 100 000 GPD• Copy to DWR,CCPCUA
g
13a.field m BIOW Permit Program,1611 MSC,Raleih,NC 27699-16I t
(gP ) Method of test:
13b.Disinfection type: HTH Amount 1 lb.
Form G W-l
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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