GW1-2022-03585_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.NATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A ft. ft.
a. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased Yells)OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
rt. ft.
Company Name
5 (l� 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(r.e.UIC,County,State,variance.etc.) ft. tt in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
❑Agricultural ❑Municipal/Public
FROM TO DIAIIIETER SLOTSIZE THICKNESS IATERML.
ft. tt in.
❑Geothermal(Heating/Cooling Supply) OR sidential Water Supply(single) ft ft in
❑bndustrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrl ation ❑Wells>100 000 GPD FROM TO MATERIAL, EMPLACEMENT 5IETHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Ground water Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK if a licable
Ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control n. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionnl sheets if necessary)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) ERoM TO DESCRIPTION color,hardness soillmck type,grain size etc.
ft. ff ' Gilt rt
4.Date Well(s)Completed - `Z Well ID# an IPM
Lft. ft
5a Well Location: ft. ft.
t`�a S�tl(f ft ft MAR 2
Facility/Owner Name Facility ID#(if applicable) ft• ft• pro0
a7N1 A1(",x ft. ft
Physical Address,City,and Zip ft. ft.
AA.rj fp0 2LREMARKS
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.Certiftcat•
MlI"W1 N W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)it-as(were)cotsstructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 01C.0100 or ISA NCAC 01C.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 ofthis record has been provided to the well owner.
repair under#21 remarkT section or on the back ofthis 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: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
Far nttdiiple wells list all depths tfdVerenr(example-3@200'and 1@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2 V (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If rroter 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 276994636
12.Well construction method: 24c.For Water Su 1 andO en-Loor W
Geothermal Return ells:Copy to the
FOauger,rotary,cable,direct push etc.) county-environmental healt department of the county where installed
OK WATER SUPPLY WELLS ONLY: �
7�( 24d.For Water Wells Droducing over 100,000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) V Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699- 6611
13b.Disinfection type: HTH Amount: 1 lb.
Fort GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018