GW1-2022-03557_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3441A Z15 ft. a7� It
s;G
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DLNfETER THICKNESS MATERIAL
Company Name /
...J-. - ft. %34 ft. '.. in. % ! ' (v,' -C!.
` 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:ZJ-LJ" y S-5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.WC,County,State,Variance, tc.) f[. ft. in.
3.Well Use(check well use): fL ft. ra
`Voter Supply Well: 17.-SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (kesidential Water Supply(single) ft. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLA MENT METHOD&AMOUNT
Non-Water Supply Well: CJ ft. 2 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 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type, rain size,etc.
tL tt S t c.
4.Date Well(s)Completed: ` Z ( Well ID# 2 ft. I 11 ft. C Al y
5a.Well Location: ft. 36 5'ft.
y I J e 14 e (on rt. rt.
t-
Facility/Owner Name Facility ID#(if applicable) ft. rt. -
2 z o ( b Ifs S&rat:i t �� c� A v 6 ft. ft. R 2 2 7o2,)..r.
Physical Address,City,and Zip a 76 < ft. ft.
21:REMARKS ' l
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifreat'
(� f� R: g
✓.1.G V t y/� N -1 b.i i� W W 7- 1
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the tvell(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 01C.0100!fell Construction Standards and that a copy
If this is a repair,fill out known ivell construction information and explain the nature ojthe of this record has been provided to tire well onmrer.
repair under 921 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-i is needed. Indicate TOTAL NUMBER bf wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
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 ifdierent(example-3@200'and 2@I00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,are"+`
11.Borehole diameter: CJ (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 Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental heal department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
Blow Permit Program,1611 MSC,Raleigh;NC27699-1611
13a.Yield(gpm) Method of test:
HTH 1 lb.
13b.Disinfection type: Amount:
i
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018