GW1-2022-03560_Well Construction - GW1_20220322

al Use Only:
WELL CONSTRUCTION RECORD(GW-1)
For Intern
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 1Ca fp 675 ft.
3441 A /GJ
rt. rL
NC Well Contractor Certification Number 15.:OUTER CASING.for multi-cased wiN OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER! THICKNESS MATERIAL
ftft. ft. A 1
Company Name ' 16.I ER CANING OR TUBING eothermal closed-loo
2.Well Construction Permit#: L.CJZI FROM TO DIAMETER` THICKNESB MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in
�-
3.Well Use(check well use): ft. ft.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothemial(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPL EI1tENT METHOD&AMOUNT
Non-Water Supply Well: ft. V
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL:PACK if applieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I 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 necessary)
FROM TO DESCRll T10N color,hardness soiUrock •q grain size
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks etc
ft. ft. d P L
4.Date Well(s)Completed: d-'?2 Well ID# ft. ft.
Well Location: (t. ft. rtkn�r L�
n ft tL
Facility/Owner Na/m�e� Facility ID#(if applicable)
ft. f4
�d JV KiG' W 1��� 6 ft. ft. r —a.
Physical Address,City,and Zip e1 �QQ3 ft. ft
r (Son Oc V r 21.REMARKS
VA 2
County Parcel Identification No.(PIN) �0 '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certitice'
W
6.Is(are)the well(s): ®Permanent or ❑Temporary signature ofCenified well Contractor ` Date
By signing this form,I hereby certify thai the ivell(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ojthe ojrhis record has beenr provided to the nI owner.
repair under#21 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 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: f L e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iJ different(example-3 tt 00'and 2@I00)
"7 A 24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWI,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open!Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producingiover 100,000 GPD:Copy to DWR,CCPCUA
Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
HTH 1 lb.
13b.Disinfection type: Amount:
4
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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