GW1-2022-03742_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 DESCRIPTION
ft'
3441 A 4 Sv ft /S G
ft. ft
NC Well Contractor Certification Number `
15.01TCER CASING.[or multi-cased wel1s OR LINER ita licable
NW Poole Well and Pump Company FROM DIAMETER, THHCKNESS afATERLIL
ft. a ft. in. 1C
Company Name 16.INNER CASING.OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(1.e.UIC,County,State,Variance,etc.) ft. 4f,
in.3.Well Use(check well use): ft' in.
WaterSupply Well: FROM
SCREEN.
FROM TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural `$Municipal/Public 81
ft. v3 fL f in. a 0
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in
❑bldustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01rr1 alion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 "' 3;2 ft. FNTr1T ,=
❑Monitoring ❑Recovery ft ft.
Injection Well:
ff. ft.
❑Aquifer Recharge ❑Groundwater Remediatioh
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• o3 ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soillmek a rain size etc.
❑Geotltennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) G ft. it. O }�so f
4.Date Well(s)Completed: Well ID# ft. AJE!' n' 5A,✓�
5a.Well Location: ft. ft. S/�N AS 1 c'V OF-
7
� IeA K,�� Site ft ft
Facility/Owner Name FacilityID# ifs licable ft. ft
,fl AA TdN 54,&Dw11 ft•�✓ { IIK(,NTo,.� ft. ft.
Physical Address,City,and Zip fi. ft. 2029
/
Q/�NI��,//v 21.RE51ARKS
Y'� Irk
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(ifss•ell field,one]at/long is sufficient) 22.Cerlifieat'
3(0- 0539 07 N r� 3 W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the u•ell(s)n•as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a coP),
If this is a repair,fil/out,brown ivel/constructions information and explain the nfa'ture of the ofthis record has been provided to the it-ell owner.
repair under#21 remarks section or on die 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 I GW-I is needed. Indicate TOTAL NUMBER of"yells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Dt� (ft.)
Fw•nwhiple wells list all depths ifdtTerent(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: U (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I/'n•ater Jerel is above casing,use"+" Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Inlection Wells:Copy to DWR,Underground hijection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 127699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Open_Luop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pussy etc.) couni7 environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinj over 100,000 GPD: Copy to DWR,CCPCUA
BIQW Permit Program,1611 MSC,Raleigh,NC 27699-16 1
13a.Yield(gpm) 0 Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-l North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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