GW1-2022-03582_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 I DESCRIPTION
3441A log ft. (off ft. �, i4
NC Well Contractor Certification Number 176 ft. "S IL K" f
15,OUTER CASING Tor multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
- fr. 77. ft. 1,,- At
Company Name , _
16.INNER CASING.OR TUBING eothermat closed-loot))
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(r.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in-
Water Supply Well: SCREEN.
TO DIAMETER SLOTSILE THICKNESS MATERIAL
❑Agricultural )dMunicipal/Public ft. it. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ❑. in
❑biduslrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: G ft. 717 fL N4
❑Monitoring ❑Recovery M ft. f/
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if o licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets if necessary).
❑Geothermal(Heating/Cooling Return rks❑Other(explain under#21 Rema FROM TO DESCRIPTION color hardness soiUrock a rain size etc.
O ft. J, ft. 1
4.Date WeII(s)Completed: Z t 1 Z�Well 1D# ft. tt. 1
ft. r
5a.Well Location: ft. f
/o,�t 9AN11 L. ft. TL
Facility/Owner NameI j , Facility ID#(if applicable) ft. ft.
6 � ViD1u lJ 1 / ft. ft.
13f�XTary C O�NrYITy l�_l�t�/4�lNT oN�
Physical Address,City,and Zip ft• ft. urs;
FAeLIM .1LREMARKSrr AADD y
County •"� Parcel Identification No.(P[N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JoAV
(ifwell field,one l'fat/lloonngisis sufficient) �L 22.Certffica'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this fornt,I hereby certify that the tvell(s)was(ivere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Neil Coistruction Standards and t/tat a copy
Ijthis is a repair,fill out know it well construction information and explain the nature of rile of this record has beenprovided to the ivell oivner.
repair under 921 remarks section a•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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (t V B,)Far multiple,yells list all depths ifeli/fereni(example-3@200'and 2@100') Submit this GW-I within 30 days of well completion per the following:
10.,Static water level below top of casing: �U (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifiroter level is above casing,use"+°/ 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 Su 1 and Open-Loop 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 SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0 Method of test: Biow Permit Program,1611 MSC,Raleigh;NC 27699-1611
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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