GW1-2022-03734_Well Construction - GW1_20220330

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
3441 A 17 K 1 rt. L ,yl
ft. IrL
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
NW Poole Well and Pump Company FRO51 TO DIAMETERi THICKNESS MATERIAL /
ft. '�71{... ft. - lio.� I 1 0 e'I V�, X
Company Name / I
// /� r �Cam�'�-0 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#:(/ W" 6S09J" t FROM TO I DIAMETER' I THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): tr. ft.
Water Supply Well: .17.SCREEN
FROM TO DIAMETER ;SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. rt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z� ft. of �f� D
❑Monitoring ❑Recovery ft. ft. ,
Lnjection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACE51ENT METHOD
❑Aquifer Test ❑Stonnwater Drainage R R.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soilfrock type,gra'n sin,etc.
❑Geothermai(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. I ft.
pC
4.Date Well(s)Completed: / -2 Well mit ft. 7L ft.Cse
C
5a.Well Location: W ft. Q ft.
M('yY1 (t 5+ b K/ ft. rL
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. „ / ,i,Y:-• .. 4p _,h
97s t 20C' d ttJer I� .rr� ,s r
ft. ft. -�
Physical Address,City,and�tip 1? '7-19( ft. ft. MAR 3 0 202?
I/V 11J(- 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude sad longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certifical'
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor a Date
By signing ibis form,I hereby certify that die trell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo 15ANCAC 01C.0100 or 15ANCAC 01C.0100 11'ell Cotutuclion Standards and that a copy
Ifthis is a repair,fill out Apan77 well construction it jornhalfon and explain the nature of the of this record has been provided to the wel/oivner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
3.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
�S 24.SUB111fITAL INSTRUCTIONS
9.Total well depth below land surface: (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: b ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifiroler level is above casing,use ,+,, ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:(i.e.auger,rotary,cable,direct push etc.) 24c.For Water Supply and Open-Loop Geothermal ReturnWells:Copy to the
county environmental health department:Ff the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over;100 000 GPD•Co to D py WR,CCPCUA
13a.field m Blow Permit Program,1611 MSC,Raleigh,NC 27699-1
(gP ) Method of test: 611
1.3b.Disinfection type: TH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018