GW1-2022-03729_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14:WATER ZONES
FROM T D
Well Contractor Name FSCRIPTIONft. ft. f�,
3441 A . 51 30s- ft. 1 U ft /{ !t-i_
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Well OR LINER if a liable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS DATERIAL
i ia. V T j f°,k,Cj
Company Name ) /`(/�(f 16.INNER CASING OR TUB G eotherma►closedV-loo
2.Well Construction Permit#:f/ V�/ - V`'I�1�7_2-0 2- FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN,
FROM TO DIAMETER SLOT SIZE THICINESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in
❑Geothermal(Heating/Cooling Supply) yRResidential Water Supply(single) ft. ft. in.
❑btdustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑lyri ation ❑Wells>100,000 GPD FROM I TO fATERIAL EMPLAC NT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Vey
la z
❑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)
❑Geotherm FROM TO DESCRIPTION colaardnesoil/roe,grain size etc.
al(Heating/Coolingueturn) ❑Owner(ex lain under#21 Remarks) ft. fr.
4.Date Well(s)Completed:. Z/ Well ID# ft. ft.
a.Well Location: [t.
e-6�8 1 IC, Cvn,5. ft. M
Facility/Owner Name /Facility ID#(if applicable) ft. ft
tILL(� bo
( 1 �l ,•n 14 � ft ft. -
PhysicalAddress,City,and Zip
LI&ice 6 2LREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certifrcat'
35 ,cQoI N `.�(�• -W 1 ,
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor 1` Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 01C.0100 or 15A NCAC 01C.0200 iVel/Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofilds record has been provided to the well burner.
repair under#21 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS''
9.Total well depth below land surface: _�C// (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24 (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: K7 (in,) 24b.For Injection Wells:Copy to DWR,Underground injection Control(TUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Su I and O en-Loa Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental healt department of the county where installed
FOR WATER SUPPT ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) I Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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