GW1-2022-06398_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
I.Well Contractor Information:
Landon Phillips
14.WATER ZONES.
1Vell Contractor Name FR At TO DESCRIPTION
3441 A rL 6 ft- f
NC Well Contractor Certification Number rt. ft
NW Poole Well and Pump Company FRO uTERcTOixc farmrMA E ERe� OTIiICYKER NESSfa ItnIAIERIAL
ft.
ft.
in.
Company Name I
t/(J�� �Q�f 16.INNER CAS G OR TUBING eothermel closed-loo
2.Well Construction Permit ft: V W 1 FROM TO DIAMETER THICKNESS 51ATERIAL ^
List all applicable Well construction pernnts(i.e.UIC County,State,Variance,ete) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;SCREEN
❑A ricuhural FROaf TO DIAMETER SLOTSIZE THICKNESS MATERIAL
g ❑Municipal/Public it. tt. In.
❑Geothermal(Heating/Cooling Supply) 4IResidential Water Supply(single) ft. ft. in
❑hndustrial/Comimercial ❑Residential Water Supply(shared)
18.GROUT
❑hTl atioll ❑Wells>100 000 GPD FROM TO MATERIAL EMPLAC LENT METHOD&AMOUNT
Nou-Water Supply Well: R. ft.
❑MonitoringWWI �J(
❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salmi Barrier .19:SAND/GRAVEL PACK if a llcable
h' FRODI I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Ston.nwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. ft.
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRO51 TO DESCRIPTION color hardness sallhock e, rain size etc.)
p' d ft. tL � �� ;`C
4.Date Well(s)Completed: —0 —Z Well ID#
�I
6a.Well Location: ft. �ff ft.---
t.
l�t° C, ..?C t/CL C- n. rr
Fa il'ty/Owner Name Facility ID#(if applicable) ft. ft.
Physic�al)Address,City,and tp 75F [ ft. ft. a �'
�7 .21.REMARKS
—v t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ .•.,,T
(if2well field,one llaatt/'lornggis sufficient) ¢
22.Cert x•� ,r�^�^�"� " + I' Jn
N O .�35O if'nca' {l i t�'i6ir,i 1L I�P I 1��' '
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature ofCertified well Contractor Date
By signing this form,I hereby certty that the,vell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mo 15ANC4C 02C.0100 or ISANCAC 02C.0200 1Vell Construction Standards and that a copy
Iftltis is a repair,fill out known Nell construction h fornation and explain the nature ofnte afthis record has beery provided to the,veil owner.
repair under 021 remarks section or on the back of dils 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 into
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: c S ft.
For n,dtiple,yens list all depths tfdVerent(example-3@200•and 2X@100) ( ) Submit this GW-1 within 30 days atiwell completion per the following:
10.Stake water level below top of casing: V ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
1J water level is above casing,use"+ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: k� (in,) 24b.For Injection Wells:Copy to DR'R;Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,
12.Well construction method: 24c.For Water SUDDIy and Open-Loon Geothermal Return Wells•Copy to the
,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells aroducine over 100"0 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) J Method of test BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection h'P •e:' HTH Amount: 1 lb.
,
Form GW-I North Carolina Department orEnvironmeatal Quality-Division of Water Resources Revised 6-6-2018