GW1-2022-03561_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 rt• 0s rt.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells 0R LINER if a livable
NW Poole Well and Pump Company FROM T D ETER THICKNESS MATERIAL
Company NaNameft. ft. j is . I-�V
O 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft. ,i in.
3.Well Use(check well use): rt. It.
in.
Water Supply Well: 17.SCREEN.
FROM . TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. fr. io:
❑Geothermal(Heating/Cooling Supply) }.Residential Water Supply(single) n R im
❑hldustrial/Commercial /❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100000 GPD FROM TO MATE EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: R. ft. Q 4
❑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 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 ifnecessa
❑Geothermal(Heating/Cooling Return)'', ❑Other(explain under#21 Remarks) FROM To DESCRIPTION Color hardness il/mck type,grain Aw,etc.
ft. ft. t7 j
4.Date Well(s)Completed:Z-f f_2 Well ID# ft. tr•
5a. 11 Location: 6 R. ft. ti r7
e(Itliyi �o o egoA ft. ft
Facility/Owner Name Facility ID#(if applicable) tt ft
n Igo d 51 m' N c ? 0 W ft. f,
hysica)Al ddress,fity,and Zip ft. ft.
W tl 56)n 2LPEMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) rr II,, 22.Certificat'
�57• -7 2-4-45 N - "7� t I Z�O`t� W
o - 11 �Z2
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby cerr�that fire well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A 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 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
( L 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _`t/� (R') Submit this GW-1 within For multiple wells list all depths ifdii ferent(example-3@200'antehd 1@100) n 30 days of well Completion per the following:
10.Static water level below top of casing: Z V (B) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water 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
24c.For Water Supply and O en-Lao Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPL)I SELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) I Method of test: Blow Permit Program,1611 MSC,Ra ei NC 27699-1611
13b.Disinfection type: I-ITI-I Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6.2018