GW1-2022-03732_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.IV ell Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A ' ft. ft.
rt. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO DIAMETERr THICKNESS MATERIAL
Company Name ft. �
l�+ //�/� 11.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: (�(7(� �(J FROM TO I DIAMETER I 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. (t. in.
17.SCREEN
Water Supply Well: FROM * TO DIAMETER SLOTSIZE THICIQVESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothennal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO D TE EMP CEMENT METHOD&All OUNT
Non-Winter Supply Well: ft.
❑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 MATERIALi I EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness saiUrock type, rain siu etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft. ft.
4.Date Well(s)Completed: Well ID# ft. tt.
51.Well Location: le ell ft.
�CiG�n 6 "-Qfl11;L C rt. ft. LI
r
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Sty J 7 #6 Pt,n S C&A L IM Z duci)n ft. ft. MAR 3
Physical Address,City,and Zip . fC. a 751 7 ft. ft.
21;REMARKS el_ r" r f, t
County Parcel Identification No.(PIN) %?. cntiyy^�'';
i l-v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifNvell field,one fat/long is sufficient) 22.CertificaY
3s. e`� N - -7 g- 3s5
W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the ivell(s)was(it-ere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo ISA NCAC 01C.0100 or 15A NCAC 01C.0100 1Vell Construction Standards and that a copy
if this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section at-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 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
65 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft.
) Submit this GW-1 within 30 days of well completion per the following:
For mrdtip/e u•¢/!s list all depths ifd ¢ren!(example-3 tt 200'and 2@I00') (
10.Static water level below top of casing: Z0 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If wale),level is above casing,use'+/-_ (ft.)
) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: p (in,) 24b.For Injection Wells:Copy to DWR Underground Injection Control(ILIC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
i..Well cmiry,cable,
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 producing over.100 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Blow Penn tt Program,1611 MSC,Raleigh,NC 276997 11
13b.Disinfection type: HTH Amount: 1 lb.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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