GW1-2022-03631_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 DESCRIPTION
3441 A '�-o ft. ft. 5 m
NC Well Contractor Certification Number
31 p rt. rt. z /-eA
15.OUTER CASING for multi-cased ells OR LINER if a livable
NW Poole Well and Pump Company FROM To DLAIETERI THICKNESS MATERIAL
r
Company Name -�- tt• � ft. / o.
16:INNER CASING OR TUBING eother at closed-loo
2.Well Construction Permit#: FROM To I DIAMETER] I THICKNESS I MATERIAL
Lis(all applicable well construction permits(t.e.VIC,County,State,irariance,etc.) ft. ft. fin.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.'SCREEN
❑Agricultural ❑Mlmicipal/Public
FROM TO DIAMETER ;SLOTSIZE I THICKNESS I MATERIAL
it. ia.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n, ft. to
Wndustrial/Commercial ❑Residential Water Supply(shared) 1S GROUT
❑11T1 orlon ❑Wells>100000GPD FROM I TO MATERIAL EMPLACEIIMENTMETHOD&AMOUNT
Non-Water Supply Well: fL ft o -
❑Monitoring ❑Recovery ft. rt.
Injection Weil•
❑Aquifer Recharge ❑Groundwater Remediation ft. ft. `
❑Aquifer Storage and Recovery ❑Salim Bier 19.SAND/GRAVEL PACK if a ticable
tyarr FROM TO MATERIAL! EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach Additional sheets if necessa
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color hardness soil/rock type,grain size eta
ft. '2 ft. TbP `
4.Date Well(s)Completed: �f 7-2-E! Well ID# ft. ft. %
5a.Well Location: / tr. 39 rt. �llt
Sct�-OrC CA.( r ft. ft.
Facility/Owner Name {{ Facility ID#(ifapplicable) � �
I W Awn PV/f/64,i 2� W e r ��i ft ft e e
Physical Address,City,and Zip fL ft. MAR 2 8 2022
2L REMARKS
County Parcel Identification No.(PIN) kgo"AaWn Prat;Q9.wng Unh
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22�Cerfflfilca
3S7.(ao Z N -�� W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertifi sd Well Coatractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 01C.0100 or 15A NCAC 02C.d200 Well Construction Standards and that a copy
If this is a repair,f/l out known well conzsiniction Information and explain the nature of the of this record has beenprovided to the well owner.
repair under#21 remarks section or on the back ofthis form. i
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 constriction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may AND attach additional pages if necessary.
drilled: 1
24.SUBMITTAL IlVSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths tfdtTerent(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: 26 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ifuater level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:(i.e.auger,rotary,cable,direct push etc.) 24c.For Water Supp1y and Open-LoOD Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100"0D GP •Copy to DWR,CCPCUA
13a.Yield(gpm) L V Method of test: BIOW Permit Program,1611 MSC,Raleigh,NC 27699-161 i
ii
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources I Revised 6-6-2018