GW1-2022-03735_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 TO I DESCRIPTION
3441 A 'd ft. 16 rt. 1 '.
ft. rt.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a Iicable
NW Poole Well and Pump Company FROM TO DIAt11ETER THICIflNFSS MATERIAL
Company Name ft. 12
ft. in l 6Z t ✓t�Y.r�
� 0 �7 _ 16.INNER CASING OR TUBING(geothermal closed-loot))
2.Well Construction Permit#: / '- v`'1 7 7'5r?-�ye � FROM TO DIAMETER THICKN I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): {t. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) iesidential Water Supply(single) it. ft. 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: O ft. �7 - ft. �G v✓
❑Monitoring ❑Recovery ft. tt.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TEL DESCRIPTION color,hardness •soillrock type, rain size etc.
ft. ft. 5 s'- C
f u
4.Date Well(s)Completed:1 _y' Well ID# ft. C ft•
5a.Well Location: ft. ft.
j� L
IJ �+hA SyU W ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft. F 1
rTt�1� !� c� 4.Ca/�'!� �/'/� ft. ft �
Physical Address,City,and Zip ft, ft.
u-(G. �'c a7s 1
11.REI+rnRxs
County Parcel Identification No.(PIN) r 3 elf.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) '] .22.Certifiieat.
)_ N ' f. 1 W ` q z
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fornt,I hereby certify that the ivell(s)ivas(were)catuirtcied in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a copy
If this is a repair,fill out Intown well construction i formation and explain the nalure of the ofthis record has been provided to the well owner.
repair render#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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: As 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: ft 24.9. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use^b ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: v (in,) 24b.For Injection 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 24c.For Water Supply and O en-Loop Geothermal Return Wells:Copy to the
etc.) county envirownental health departmentof We county where installed
P012 WATER SUPPLY W LS ONLY: 24d.For Water Wells producine over 100 000 GPD• Copy to DWR,CCPCUA
1 BLOW Penult Program,1611 MSC,Raleigh,NC 27699-1 6 11
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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