GW1-2022-03556_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Lalld011 PhIIIIpS 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A 105 ft Ao rt• �1 G "I
NC Well Contractor Certification Number ft. INK ".
15.OUTER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER' TRICKINESS MATERIAL
ft ft i;a.
Company Name
�(p �^( q 16.INNER CASING OR TUBING eothervsol closed-loop)
2.Well Construction Permit#: l7 Oa� /"" -V 6J 1 FROM TO I DIAM TER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Parlance,etc.) •S •ft. S ft. in.
• v L f�
3.Well Use(check well use): ft. m in.
Water Supply Well: 17,SCREEN.
❑A ricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
g ❑Municipal/Public R, R, ILL
❑Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft. in '
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ICrI ation ❑Wells>100,000 GPD FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. t7 ft. ;F"Toa"X'
❑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 I MATERIAL! I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft,
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness sonfrock ruin size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks t7 q ft. o
4.Date Well(s)Completed: - ;/ Well ID# tt. P ft. S�'V A A`
5a.Well Location: ,.rr- �� tt. ft. GR AN S 1 T� /A r TO f
6w"J'V PC I 1 I
ft. ft. —
Facility/Owner Name f� Facility ID#(if applicable)
ft. ft.
q01 b SA"LS A b RAL c ' W It. ft 2
Physical Address,City,and Zip ft. ft.
�li�Ou 2LREMARKS r•: c, r=7;;'„s
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertiTicat'
W 0101
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forn,I hereby terrify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 reniarla 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 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "); l 5' (fL)
For multiple wells list all depths ifeli ferem(example-3 200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
(ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
Ifwater level is above casing,use"+" ` Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: t! (in,) 24b.For Injection Wells:Copy to DWI,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 276 99-1636
12.Well construction method: 24c.For Water Su I and O en-Loci Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of the county where mstalled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
Blow Permit Program;76I I MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: I il"I I Amount: 1 lb.
f
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018