GW1-2022-03578_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only'
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A ft. ft. Si /h
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LAVER i[ap licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS I MATERIAL
tt fr. t GAlU
Company Name n.n
[\ (J� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: o `9 1� FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable'Pell construction permits(.e.UIC,County,State,,Parlance,eta) ft. ft. '',in.
3.Well Use(check well use): ft. ft. in:
Water Supply Well: 17.SCREEN_
❑A ricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
g ❑Municipal/Public ft• ft. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. R. lit. ,
❑industrial/Commercial ❑Residential Water Supply(shared)
I&GROUT
❑Irrl ation ❑Wells>100.000 GPD FROM TO ATERtAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: D n, ft O QtJ
❑Monitoring ❑Recovery tt. tt.
injection Well:
ft• ft.❑A uifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO. I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt.
❑Experimental Technology ❑Subsidence Control ft. ft,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if nece1
❑Geothennal Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sol0rncki a rnin size etc
tt. ft.
d t L
4.Date Well(s)Completed: -I��2 Well ID# m ft. Y
5a.Well Location: 2 ft• J425 tt.
lt1 �t i w ft.
c�
Facility/Owner Name Facility M#(if applicable) ft, ft.
Sal q xbbi c(C �,'� rlx��, /lJc ft. ft. i
_
Physical Address,gityf,and Zip J 7 7�� ft. ft.
1-,nit 6t. 21i REMARKS
MAR LILL
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.Certificat'
N _ - 7 .T60369 W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date _ 2
By signing this form,I hereby certify that the well(s)'vas(mere)consovcted in accordance with
7.is this a repair to an existing well: ❑Yes or ®No 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out kntomn ivell construction information and explain the nature of the ofdtis record has been provided to the'vell 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 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:
//��
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: +� 6- (n,)
For multiple wells list all depths Ifdgerent(example-3 00'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 26 (R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifirater level is above casing,use^+' Infomtation 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.e.auger,rotary,cable,direct push,etc.) 24c.For Water SuRRI and Open-Loop Geothermal Return Wells-Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY W LS ONLY: 24d.For Water Wells roduchi over 1. 000 GPD:Co to DW
R,WR CCPCUA
13a.Yield m BIOW Permit Program,1611 MSC,Raleig ,NC 27699-1611
(gp ) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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