GW1-2022-03638_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Landon Phillips 4 WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A 00 rt. 30J rt.
ft. rr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ivells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL —/
' ft. '� ft.
in. I / Le 1 VJAGiC'
Company Name
/ .16.INNER CASING OR TUBING(geothermal dosed-loo
2.Well Construction Permit#:CS�W'— �5� /C o FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu ipal/Public it. tL in.
❑Geothermal(Heating/Cooling Supply) esidemial Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nmr-Water Supply Well: ft. Z U rt. bcel t y r
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
''19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier 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 necessary).
FROM TO DESCRIPTION color,hardness sellfrock rain aim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks ,
f ` Z ft. ��P S'U e e-
4.Date Well(s)Completed: 7--7_ / Well ID# ft. ft.
511.Well Location: 17 ft. It. fin i�2
ft. t: ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
y-?7 1B lA<<e woody t`7 r i 0 e a ire. ;A ft. fG p
Physical Address,City,and Zip �(/� a 7Sa� ft. ft. f YIAR 2 O 2022
21:REA4A,RKS
County Y v t� Parcel Identification No.(PIN) �rt�dD�ftOL ^r2�#tf� Ur*
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong i'ssssuffficient) 22.Certificat'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertified Well Contractor Q Date
By signing this form,i hereby ceri fy that llte wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No i5A NCAC 02C.0100 or 15A NCAC 02C.0200[Veil Construction Standards and that a copy
If this is a repair,fill out known ivell 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 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 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land.surface: 3 9J (fL)
For multiple wells list all depths ifdJJerent(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: 2® (P 24s. 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: (in,) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
RotaryProgram,1636 MSC,Raleigh,NC 27699-1636
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
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Well producingover 100,000 GPD:Copy to DWR,CCPCUA
s
13a.Yield m Method of test: Blow Permit Program,161 MSC,Raleigh,NC 27699-1 6 1 1
(gP )
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i
t
i