GW1-2022-05518_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM T DESCRIPTION
3441 A 6 p ft. rt. So TAlb
rt. 1c.
NC Well Contractor Certification Number 15.OUTER CASING for mu1N-cased wells OR LINER if a licable
NW Poole Well and Pump Company FROM TO D ETER THICKNESS MATERIAL
ft. ft. iw . I IF v/
Company Name 16.INNER CASING OR TUBING eotherma]closed-loop)
2.Well Construction Permit#: SSS V / FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits rt.e.UIC,Coun State,Variance,etc.) fL ft. In.
3.Well Use(check well use): ft ft. in.
WaterSupply Well: 17,SCREEN.
FROM . TO DIAMETER SLOT SIZE THICKNESS MATEAIAI,
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) g, ft. la
❑bxdustrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irri ation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. � fi. vve
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if appiivable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) I FROM TO DESCRIPTION color,hardness soilfrack rain size etc.
O ft. 2 ft. J
4.Date Well(s)Completed: 2_( 0 _Z Well ID# ft' L ft.
5a.1 Well Location: ft. if. L�
:kt r4i'Ve ft. tt
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4 SO W i n�Iess i-f i . c lc�y � �1/e ft. fLHErT
-
Physical Address,City,and Zip 2 7 S 2 ft. ft.
30 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifies'
N W _ rZ
6.1s(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Nell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: t l`l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !V S (ft.)
For multiple,vel/s list all depths ifdierent(example-3@2000^0'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: DLO (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: (in.) 24b.For Infection Wells:Copy,to DWR,Underground Injection Control(TUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and O e I n-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 roducioIt over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) .S Method of test: mit Blow Per Program,1611 MSC,Raleigh,NC 27699-1011
13b.Disinfection type: HTH Amount: 1 lb.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018