GW1-2022-03645_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.NVATER ZONES
FROM TO DESCRIPTION
Well Contractor Name �7W ft. `I 5 ft. ( Irl
3441 A C-KJ J
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased ivells OR LINER if a licable
NW Poole Well and Pump Company FRO5I TO DIAMETER THICKNESS MATERLL
ft. r ft. -% in. ; f f'e
Company Name f� O
�] 16:INNER CASING OR TUBING etithermal closed-too
2.Well Construction Permit 4: 1 r� — J J I�2 2 FROM TO DIAMETER THICKNESS MATERIAL
List all dPplicable well construction permits(.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 4Residential Water Supply(single) ft. ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO - M TERIAL EMPLACE LENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2 ft. / U
❑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 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)
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,bards soiUrock type, rain stm etc.)
tr. fr. �! ;.
4.Date Well(s)Completed: 2 Well ID# ft. 2 - ft. C144
5a.Well Location: ft. ll ft. _ -
Q ft. ft
Facil/i�ty/Onvuer Name Facility ID#(ifappticable) ft. ft. e
_ G7 `r`nJ j U�•,, 5 (it�'�t % l.t!-flow 5!�/,Yi ft. ft.
Physical Address,City,and Zip 7 S y ft. ft.
t s p� 2 2L REMARKS
County V Parcel Identification No.(PIN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long fi
is sufficient) 22.Certi
((
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contactor ! Date
By signing this form,I hereby certify that the ivell(s)u•as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C:0100 lirell Construction Standards and that a copy
If this is a repair,fill out Armor well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Gcoprobe/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-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
9.Total well depth below land surface: of well Submit this GW-1 within 30 days completion per the following:
For nudtiple ivelis list all depths ifdi,/ferew(example-3@200'and 2@100') ) y p p g'
10.Static water level below top of casing: eft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifirater level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 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 O en-Loo Geothermal Return Wells:Co to the
(i.e.anger,rotary,cable,direct push etc.) county—environmental heal department of the county where installed Copy
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: BIOW Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: TH Amount: 1 lb.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018