GW1-2022-03636_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon PhllilpS 14.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
3441 A ts
ft. o it• .,cf 411,1
ft ft �
NC Well Contractor Certification Number [..
15.OUTER CASING.tar multi-cased wells OR LINER if a liable
NW Poole Well and Pump Company FROM TO DLIMETER THICKNESS MATERIAL
ft.
Company Name ft. in. f Jilt[-
U .J�c lil �Z02� 16:INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: W� FROM TO DIAMETER F_Tm_c_K_NF_,S­s__7 aATERIAL
List all applicable well construction permits(i.e.UlC,County,Sale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
❑Agricultural ❑Municipal/Public
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
eF❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt. in
❑hrdustrial/Commercial ❑Residential Water Supply(shared) 18:.GROUT
❑k71 ah011 ❑Wells>100,000 GPD FROM I TO ATERLIL EMP EMENT afETHOD&AMOUNT
Non-Water Supply Well: ft. 16 ft. &4CA6111
O u1-
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACK if a licable
tY FROM TO MATERIAL I 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sonfrock type,gmin size etc.
a ft. ft. d
4.Date Well(s)Completed: 1"Z Z Well ID# ft. ft. G /� f
Sa.pWell Location: "� ft. Q lft. �Mf�
. L' arum )�(YK_ ft ..Jft
FM -24
Faccilhtity/Owner Name Facility ID#(if applicable) ft ft Wit:" -
U a
f2!S h ,O,OVAS r-W B L'7-- Ore_W Ton N� ft. ft 6
Physical Address,City,and Zip OZ.7517ft. ft.
2L REMARKS
rtauailti
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Certtfreat'
N
6.IS(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby certify that the svell(s)was(were)constructed in accordance with
1.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 01C.0100 or ISA NCAC 02C!0200 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#21 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:
nC)� ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q( ft,)
For multiple wells list all depths ifdierenr(krantple-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 249. For All Wells: Original form'to Division of Water Resources (DWR),
Iftrater level is above casing,use^+^ (R') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (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 SUPPL�WELLS ONLY: 24d.For Water Wells producingover 100,000 GPD:Copy to DWR,CCPCUA
(gP ) Method of test:
13a.Yield m lJ�lw/ BIOW Permit Program,1011 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources Ef Revised 6-6-2018
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