GW1-2022-03711_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) [F—orld—emd Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
ROM TO DESCRIPTION
Well Contractor Name
3441 A fir
ft. ft
NC Well Contractor Certification Number M OUTER CASING for multi-eased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DLUIIETER. THICKNESS MATERIALry
rt. ft. im.
Company Name �j/�'j 4
eao — 6/" I�f _ 16•I CASING OR CASIN OR 1 UBIN eothermal dosed-too
2.Well Construction Permit#: FROM TO DL►AfETEA THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. m
Water Supply Well: 1Z SCREEN:
pp Y FROM . TO DIAMETER SLOTSIZE TmCKNESS atATEAIAL
❑Agricultural ❑Municipal/Public ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) QlResidential Water Supply(single) n• ft. in
❑hldustrial/Commercial '❑`Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO fATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. 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 MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary),
❑Geotltennal(Heating/Cooling Return) ❑Other(explain under#21 Rem!tli
PROM TO DESCRIPTIONcolor hardness saiUrock type, rain size etc.
ft. It.
4.Date Well(s)Completed:a-f -22 Well ID# it. ft. G
5a.Well Location: ( t ft. ft. �G
w ft ft
Muff-
Fa(cilliity/Owner Name, 1, Facility ID#(if applicable) ft. ft. P F
N0 fl A(J � - "`� ft ft. o ,
. t
Physical Address,Ci ,and Zip(J r i ft. ft. MAR 3
�FIS� ?�"IW��pf•(n3 ZI:REMARKS:
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.Cer tiftea'
3 Jt G, b?2 W Z iS-z
6.Islam)the well(s): INP7ermaneut or ❑Temporary Signature ofCcr i6ed Well Contractor Date
By signing this form,I hereby certify than the ivell(s)was(were)constructed in accordance lilith
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 02C.0100 or 15A NC,4C 01C.0100 lVell Construction Standards and that a copy
If thts is a repair,fill out knoum well construction information and explain the noture of the of this record has been provided to the trell owner.
repair under#21 remarkT 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 l 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: 2 2 S (n•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi/ferent(example-3@20 •an @i00)
10.Static water level below top of casing: (n)zo
24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater 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.Well construction method: 24c.For Water Supply and Open I-Loo Geothermal Return 1Velis: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: 14d.For Water Wells roducia over 100,000 GPD:Copy to DWR,CCPCUA
20 Biow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
V
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018