GW1-2022-03727_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14,wATERZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A 7p rt• 7S ft. t f
NC Well Contractor Certification Number
15.OUTER CASING for multi-eased'wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
fr. fr. L ;n. " P
Company Name T P ( Gs
Q �n,(�_ 16.INNER CASING OR TUBWG eothermal closed-loon)
2.Well Construction Permit#: l] Q�[��' W�I FROM TO DIAMETER THICKNESS afATER1AL
List all applicable hell construction permits 0.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
❑Agricultural ❑Municipal/Public
FROM TO DIAr1METER I SLOT SIZE I THICItatESS I MATERIAL
ft. R. is
❑Geothennal(Heating/Cooling Supply) Aesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTI ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nou-Water Supply Well: 0 ft. arldft• ,'r?err Q
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG lattach additional sheets if necessary)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness son/rock type,crain size etc.
�( el a ft. a, ft. 1,, sq
4.Date Well(s)Completed: O&/ Ne11 ID# ft• ft. D r p
5a.Well Location: ft. ft.
rL rL
Facility/Owner Name 3` p�A Facility ID#(if applicable) fL ft.3 D ��.L f d�S`JA b ft. ft.
Physical Address,City,and Zip 2` tY1 O/✓ ft. ft.
�A�F I l: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.CertiTicaC
�JS• _N = 3�3 W _ ta/00 ,
6.ls(are)thewell(s): Permanent or ❑Temporary Signature ofCertifiedWellContractor s Dae
® �
By signing ibis form,I hereby cerijo that the rell(s)teas(here)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or IlNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standen ds and that a copy
Ifthis is a repair,fill out known well construction Information and explain the nature of the of this 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 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: t /L 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (/O ft.)
For•multiple wells list all depths ifdiJferent(example-3@200'and 2(a)100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �� (ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water lore!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 O en-Loci Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department of a county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gP m) Method of test:/� Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Fonn G W-t North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 6-6-2018