GW1-2022-03613_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14,WATERZONES
FROM TO DESCRIPTION
Well Contractor Name f 3441 A (, ft. r & ft. /S i ,
NC Well Contractor Certification Number 5 ft fL S Lt
15.OUTER CASING [or multi-cased e s OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
ft. 7`'
Company Name
`S 7pL 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: t% W—V l7 /3 —O2 (� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. eb ft. in.
❑Geothermal(Heating/Cooling Supply) tsidential
sidential Water Supply(single) tt. R, in.
❑industrial/Commercial Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT INIETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(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 soil/vck type, •n size etc.
0 ft. a ft. SG,t t
4.Date Well(s)Completed: Well ID# Z ft. ` ft. C JGt y
5a.Well Location: ft. ft.
'Trams+e r5 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
—a(M&a LL i I L Ld'alllot-, '56.. ft. ft. ry
/
Physical A� &
ddre�sss,,City,and Zip /t�C a 7S"Q it' ft' 1C
V V✓�l` 21.REMARKS caG ing UrA
County Parcel Identification No.(PiN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifteat
9 / •
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C i0100 lVell Construction Standards and that a copy
lfthis is a repair,fill out!mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 rentarks 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
constriction,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: (ft.)
For multiple wells list all depths lit dii ferenr(example-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: (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.) 246.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Supply and Open-L1oop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusl>,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
zo
13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,'NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 lb.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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