GW1-2022-03627_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 DESCRnPTION
3441 A /w ft. / , ft. c, ,,,�
NC Well Contractor Certification Number 110 tt '' ft If
G e
15.OUTER CASING for multl-cased wells OR LINER it a livable
NW Poole Well and Pump Company FROM TO DL4d%IETER THICKNESS MATERIAL
4.1.511. 1 ft. in.
Company Name • ♦ ♦T•
16.INNER CASING.OR TUBING(geothermal closed-lootil
2.Well Construction Permit#: � v0 I'll"r�"�( FROM To I DIAMETER I 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.
Water Supply Well: 17.SCREEN.
FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑Agricultural *unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n• ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ati011 ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d , av it. Ww aN C
❑Monitoring ❑Recovery ft ft. G
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheeplor ha if necessary)
El (Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION coO M no
ft. u► H. ?d D1
4.Date Well(s)Completed: / Well ID# ft- kND /
5a.Well Location:
it 'Q tt. •SIGN dN E %A Z_'
_ALLY ,%ARsAtAL4 10 n rt f
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
05JAJt34tRG b 2ES1,40y IV ft. ft
Physical Address,City,and Zip 9 ft. ft.
1✓/fk1 21.REMARKSS 1
County Parcel Identification No.(PIN) G C A "R Ee V S 6
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one W/lonnJg is sufficient) (� 22.CertiliiCat'
�� `� 30 N --��P ��`��`F� 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 well(s)was(were)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 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#11 remarks section or on the back of this farm.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You'may also attach additional pages if necessary.
drilled: 11'� 99 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .,tQ7• (ft.)
Tormultiple wells list all depths iifd�tTerent(example-3@200�and 2@100�) SubDlit this GW-1 within 30 days of well completion per the following:
10.Static water level below top ofcasing: ad (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use^+ / Information Processing Unit,.1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: D (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 Supply and Open-Loon 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) Q Method of test: Blow Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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