GW1-2022-03558_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.1Vell Contractor Information:
Landon PhIIIIpS 14.WATER ZONES
Well Contractor Name FROM TO DEC—"TION
3441 A C rt. � rt. i
rt. rt. 0
NC Well Contractor Certification Number IS..OUTER CASING for multi-ca ' ells OR LINER if a licable
NW Poole Well and Pump Company FROM I ft. TO DIAMETER TIi1CK(G�NES/S'' MATERIAL
>
Company Name
� ?? 16.INNER CASING OR TUBING eothermai closed-loop)
2.Well Construction Permit#: — �OU a r Z GL ( FROM TO DUMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. Ct. in.
3.R'ell Use(check well use): ft. tt. in.
Water Supply Well: SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft ft ;n
❑hndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL , EMP EMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20
tt. „
❑Monitoring ❑Recovery ft. ft.
Injection Well: tt. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEbIENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROI To DESCRIPTION color,hardness soittrock type,grain size etc.
�j o ft. ft.
4.Date Well(s)Completed: / Well ID# ft. ILI ft.
ft. ft. u J
Sa.Well Location:
t ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
1 aZk 14t;,rv� % 3r�h5a49c_ i I l�C.,lA ft ft.
Physical Address,City,and Zip /V
ft. ft. 11
l J I/t /- 21.REMARKS
County v` ��`www���...tec...ett Parcel ldentification No.(PIN)
'Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iflw�ellh field,
nnone]it/long is sufficient) ` 22.Certificat'
✓. �Jl��� 1 Nr .0 W -
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
Bysigning this fornh,l hereby certify that the icell(s)eras(were)constructed in accordance with
7.1s this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a cop),
lfthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well,owner.
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 uifo
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: n 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft,
Far multiple wells list all depths fdi„(jerent(example-3@200'andd)2@100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easlug: 1z ft) 24a. For All Wells: Original forme';to Division of Water Resources (DWR),
Ifu-ater level is above casing,use"+r (ft.)
Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
11.Borehole diameter: v (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 Man'
and O en-Ldo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct posit etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ov6r 100,000 GPD:Copy to DWR,CCPCUA
131.field m Blow Pernrt Program,1611 MSC,Raleigh,NC 27699-1611
(gP ) Method of test:
HTH 1 lb.
13b.Disinfection type: Amount: '
Forni Gw-l
North Carolina Department of Environmental Quality-Division of Water Resources l Revised 6-6-20 LS