GW1-2022-03581_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 DESCRn'TIOtt
01
3441 A 1 ft. 11512PA
ft. ft
NC Well Contractor Certification Number 15.OU1ER CASING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROM TO D ET ER THICKN S MATERIAL
- ft. R. . , '� I*fail,�
Company Name2 / ' .t in
. I
INNER CASING OR TUBING eothbrmal closed-loo
2.Well Construction Permit#: 3a S /S.( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.WC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN.
FROM TO m"4METER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tr. In
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rri ation ❑Wells>100000GPD FROM I TO� ATERIAL EMPLA EIVfENTMETHOD&AMOUNT
Non-Water Supply Well: R. �J ft. G J
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if applicable)
FROM TO fifATERIAL EMPLACEMENT METHOD
Test ❑Stormwater Drainage R. R.
❑Experimental Technology ❑Subsidence Control ft ft
OGeothermal(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 sail/rock a rein size etc.
�Z R. 2 tr. / Se 0, C
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ` ft. i►r'K-
f u On 6itJ f41� `t ft
Facility/Owner Name L/ Facility 1D#(if applicable) ft. ft.
Zcl Zt 00i N d79 It rt.
MAR 2
Physical Address,City,and Zip ft. ft
2L REMARKS{ rtyJ County Parcel Identification No.(PIN) D1tVt?Ij90G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
GGfield,one lat/long is sufficient) �j 22.Certifrca
N . . -�� W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 lVell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ojthis record has been provided to the well owner.
repair under#11 remarks section or on the back ojthis 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Y/J (ft)
For multiple wells list all depths tfdi ferent(example-3 a200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.)
ft, 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 Wefs:Copy to DWR Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 2'7699-1636
12.Well construction method: 24c.For Water Su 1 and O en-LoopGeothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental healt department of the county where installed
FOR WATER SUPPL WELLS ONLY: 24d.For Water Wells aroducinE over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: BIQW Perm Program,1611 MSC,Raleighi NC 27699-1611
13b.Disinfection type: i-Il I-i Amount: 1 lb.
Form GW-1 North Caroline Department of Environmental Quality-Division of Water Resources ! Revised 6-6-2018
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