GW1-2022-03626_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 1a.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3441 A ft. tr.
ft ft.
NC Well Contractor Certification Number
15,OUTER CASING for multi-cased wells OR LINER if no icable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS I MATERIAL
ft. fr. j lo.
Company Name , I
/ O` �� _ �/ FR INNER C G OR T1 DIN cothermel closed-too
2.Well Construction Permit#: (�' a,] FAOM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in-
W17.SCREEN
ater Supply Well: FROM . TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. 1L In.'
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) B n in.
❑htdustrial/Commercial /❑`Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fr. it. O PJ U
❑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 MATERIAL I EMP[ACEMENT METHOD
❑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 I TO DESCRIPTIONcolor hardness soilfrock 'nske eta
ft- tr.
9
4.Date Well(s)Completed: " 2 Z Well ID# e2 It. It.
5a.Well Location: f ft. iee5 ft'
f
Jared LLGft. ft.
Facility/Owner Name Facility IDk(if applicable) ft. fL
5226 At u,4 r ici7 it�e �71v1 ft.
Physical Address,City,and Zip Vft. ft
21:REMARKS. 1
County Parcel Identification No.(PIM 1rft 't 03n, PrciceGzing U0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellll fieldd,,�one fatllon�g7is sufficient) 7 22.Certitlea
SJ: f /�N 1� ��� W CZ-V G,
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCettified=IlCotra.w �� Date
By signing this form,I hereby certify that the wells)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 01C.0100 Well Construction Standards and that a copy
If flits is a repair,fill out known well construction it formation and explain the nature of the of this record has been provided to the we'll owner.
repair under 921 remarks 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
C 24.SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: t (ft.)
For multiple wells list all depths i/di/ferent(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, z ir) (ft) 24a. For All Wells: Original forth 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: C (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 21699-1636
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
l
FOR WATER SUPPLY�VELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
(gp ) (-JJ� BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield m Method of test:
13b..Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018