GW1-2022-03639_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14r WATER ZONES
Well Contractor Name FROM TO DESCAIPTIOtt
3441 A fL rt.
rL ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased YJells OR LINER if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name /` �
ft. ft. in.
W _ �^�I 16:INNER CASING OR TUBING eofhermal closed-loo
2.Well Construction Permit#: o((J FROM TO DIMIETER THICKNESS 1.ARTERIAL
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.) M ft. in.
3.Well Use(check well use): fc ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural ❑M FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
at/Public ft. ft. is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft. ft. in.
❑bldustrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑hTl ation ❑Wells>100,000 GPD FROM TO MATE-. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ft. tt.
9 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salmi Barrier 19.SAND/GRAVEL PACK if a ticable
FROM TO III MATERIAL I FRIPLACEMENT AIETROD
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 11.DRILLIIVG LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks FROM ToI DESCRIPTION color,hardness soiltroek min shef etc.
Q6 ft d�ft. cu r
4.Date Well(s)Completed: -2f'2 Well ID# ft. ft.
5a.Well Location: ft. ft.
ryr�
3CRAIED
[� G(, G I e�"en a ft. rt. i�
Facili
itty
7/owner N.J.'/ f' �( Fja�ciliitty'ID#(if applicable) ft. ft. MAR 2 -
Q 06 V 1 �7�r,c, �QL.L.� U.I I �G` �K! NC ft ft.
UM
Physical Address,City,and Zip '1?�& ft. ft. ' �
O� nwQM
2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellsufficient)�field,one lattlong is sucient) ^� 22.Certificat'
Q� -7
10 � N - ( V 0 W -2�-2/j
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerilyy that the ivell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: V Yes or ®No 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Comiruction Standards and liras a copy
Ifthis is a repair,fill out larawn well construction information and explain the nature of die ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis forms.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t �
24.SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: g
Far multiple wells list all depths ifd ferent(example-3@200'�nand 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z V (ft.) 24a. For All Wells: Original form 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: (in•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.auger,Well construction method: 24c.For Water Su 1 and open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct posh,etc.) county environmental eal t department of a county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD•Co
13a.Yield(gpm) Z Method of test: Blow Permit Program,1611 MSC,Raleigh,N�C 27699-1611 py to D CCPCUA
I
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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