GW1-2022-06397_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14:WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft, ft.
3441 A
S7 fr. �d i
NC Well Connector Certification Number 15:OUTER CASING for urulti-case wells OR LINER if ap licablo
NW Poole Well and Pump Company FROM ft. (O ft DIAMETER I.. THICKNESS MATERIAL
-r ( 4 f U/� C
Company Name / "16.INNER CASING OR TUBIN eothermal closed-loop)
2.Well Construction Permit#: `'/` ZyZ / FROM TO DIAMETER I TIUCKNESS MATERIAL
List all applicable yell construction perinits(l.e.UIC,County,State,Parlance,etc.) ft. ft. hL
3.Well Use(check well use): ft. ft. In.
Water Supply 1Vc11: 17;SCREEN
pp FROM TO DIAAETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic Q. ft. In.
❑Geothenttal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑hrdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑kri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT 51ETHOD&AMOUNT
Non-Water Supply Well: ft. ft. G1�u
❑Motlitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E51PLACEMENT AIETROD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets If necessary)
FROM .TO DESCRIPTION color,hardness soiVrock e, rain sin,etc.
❑Geotllennal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks ft. tt.
4.Date Well(s)Completed: 1-1-5 22 Well ID# ft. ft. (L
Sa.Well Location: ft. () ft. C-
�'
r c(JSe/r ft. ft.
C la l�► � �1 f,
y Facility . ( PP ) fI ft. s.�1l9�, }Facilit/OwaerName/� r / Facili IN ifa licable /�
�/G�T sick Cfr WG.�C, �QS /'�� ft. ft. ..>
Physical Address,City,and Zip 7597 ft. ft. ..
A��'� IC
` 21.REMARKS t• _ ...- _
l''riviu2C TiUil
County Parcel Identification No.(PIN) 11
o�sF+n +\
`l 1.1 111v:1'�,�� ,[.1J�/,IYJ J
9b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lloong is sufficient) 22.Certifrcat' L ` >
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certl(y that the+vell(s))vas(were)consinicted in accordance+vidr
7.Is this a repair to an existing well: ❑Yes or ©No ISA NCAC 02C.0100 or i5A NCAC 02C.0200 JPell Construction Standards and that a copy
ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis 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 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1�0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
Tor multiple yells list all depths ifdierent(example-3@200'and 2@100)
24a. For All Wells: Original fort to Division of Water Resources (DWR),
10.Static water level below top of casing: V (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifu•ater•level is above easing,use"4-
11.Borehole diameter: X7 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(R)C)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction 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 LLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method f test:
Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
o
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Euvironmental Quality-Division of Water Resources Revised 6-6-2018