GW1-2022-03610_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Landon Phillips 14.WATERZONES
Well Contractor Name FROM I TO I DESCRIPTION
3441 A 5 ft 13'70 it•
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING for mold-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DLUMETER THICKNESS MATERIAL
Company Name I ft 2 ft. in. It
/��f/� �,l r 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: 17-W— ©�_50!f�'—201 I FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable ivell construction permits(7.e.UIC,County,State,Variance,etc.) ft. It.
3.Well Use(check well use): ft. tt, in.
Water Supply Well: 11 SCREEN.
FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. tt. in.
❑Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft. tt. In
❑Industrial/Commercial OResidendal Water Supply(shared) IS.GROUT
Olrrl atlOn OWe11S>100,000 GPD FROM TO p ATE EMP CEMENT METHOD&AMOUNT
Nou-Water Supply Well: ft. U ft. O 1
❑Monitoring ORecovery ft ft.
Injection Well:
OAquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEDIENT METHOD
❑Aquifer Test ❑StormwaterDrainage tt• ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness sail/rock a rain size etc.
tt. ft. �
p Sd . L
4.Date Well(s)Completed:3 7-Z Well ID# ft• ft• C/OL
5a.Well Location: JJ `7 ft 6 ft. Ir�nl ot-�
B 0 5.- C u s4z"I l Awy- ft. rt
Facility/Olwn'er Name Facility ID#(if applicable) ft. ft.
S3�1 I S+c,,qfCL5<,
CU (d- (N,�j� 4/C ftPhysical Address,City,and t' Q ft. ft.
(1�• 21.REMARKS UM
County c Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifrcat'
5 .q 2 l N --7 6,CoW W �-
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby certify that tire well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction i formation and explain the nature of the ofthis record has been provided to the well otwrer.
repair under 921 remarks section or on the back of this form
23.Site diagram or additional well details:
3.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
6�s ( 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: It.)
For multiple wells list all depths ifdderent(exannple-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z 6 (B 24a. For All Wells: Original form'to Division of Water Resources (DWR),
Ifwaler level is above coshrg,use ,+,, ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWI?,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply 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 WELLSONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Method of test: BIOW Pennn Program,1611 MSC,Raleigh,NC 27699-16 1 1
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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