GW1-2022-03644_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 DESCRIPTION
3441 A #90 ir. q40, ft. /C
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wens OR LINER if a Iicable
NW Poole Well and Pump Company FROM TO DIAMETER ".0 SS MATERIAL
f ft. ff ft. ' io. CAL
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: G�/`O�/ V ti/✓� / FROM TO DtpMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. ! in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMREE TO DIAIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. % in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n. R. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
1 alion ❑Wells>100,000 GPD FROM TO MATERIAL ENIPLACE51ENTMMETHOD&AMOUNT
Non-Water Supply Well: d R. ova ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACENIENT METHOD
❑Aquifer Test ❑Stonnwater 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 soillrack a rain sin etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM
ft. ft. 7 sod
4.Dnte Well(s)Completed: 4Well ID# ft. s$ ft.
5a.Well Location: 3 ft. 'p. ft. G�Q t T
s OVA7hleir Di5V ft. ft
Facility/Owner Name Facility ID#(if applicable)
rt. ft. u IF
,ASS' 4"10-(F o/!k Rop%b ft. ft. 8 2022
Physical Address,City,and Zip 6MA0 !N Oxon ft. ft.
d k f► 21:REMARKS it
County (V Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certificat
6.Is(are)thewcll(s): ®Permanent or ❑Temporary Signature of Certified Well Contactor Date
By signing this form,/hereby certify that the svell(s)Bras(were)consoucled in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.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 file ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 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: t
�O�. � 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (B' Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d�eren!(example-3@200'mtd 1 ae100) ) y p p g'
10.Static water level below top of casing: 30 (R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifsrater 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
.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 Wells producine oilier 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) , Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018