GW1-2022-06399_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 DES ntPTION
3441 A �o ft.. �S ft. G
$O ft. fL `+
NC Well Contractor Certification Number M OUTER CASING for mutts-cased wells OR LINER if a licable
NW Poole Well and Pump Company FR011I TO DIAatETER THICKNESS 11fATERIAL
Company Name ft. 3 ft.
16.INNER CASING OR TUBING eotbermal closed-lanni
2.Well Construction Permit,#: FROM TO I DIAIIIETER I TiHCKNESS 51ATERIAL
List all applicable well construction permits(r.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(cheep well use): ft. ft. in.
Witter Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt. ft. la
❑hidustrial/Cominercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO i1IATERIAL EMPLACEMENT METHOD AMOUNT
Nou-Water Supply Well: &I ft. 19 ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19:❑Aquifer Storage and Recovery ❑Salinity Barrier FROM SAND/GRAVEL PACK if alicable
TO MATERIAL I EMPLACEMENT 11IETHOD
❑Aquifer Test ❑Stonnivater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothernal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geotliennal(Heating/Cooling Return) ❑Other(explain under N21 Remarks) I FROM .TO DESCRIPTION color,hardness solilrack type,grain size,etc.)
ft. a ft. 1O tf L
4.Date Well(s)Completed: ~� Well IDN tt. It tt• �, 1 G La
Sa.Well Location: rt• S ft. is tQikN f a
5h D t' T A ft. ft
Facility/Otvuer Name G/✓ �irtl/ Facility ID#(if applicable) ft. ft.
w //7A i �Ai 2(# RD ft. ft.
1
t!,ej .
Physical Address,City,and Zip -rDG&/NG 75-1/ ft. ft. e.-.-
W 21.REMARKS r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'r��'��'=•''
(if well field,one lat/long is sufficient) ep �„ h t 4 ? (' ,� ?iV'3 Jr
N 22.Certifica l�.r��:7vu�;ILF�t01,�.,�.
S• L-4 Q W -8-dot
-6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
Bysignhig this form,l hereby certo that the trell(s)was(here)constructed in accordance iritb
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 chat a cop),
!finis is a repair,fill our knoum hell construction information and explain the nature ofhhe ofthis record has been provided to the ivell owner.
repair under#21 remarks section or an the back ofthis 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 wells (add'See Ovee in Remarks Bdx).You may also attach additional pages if necessary.
drilled: i
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓0 (ft.)
For multiple yells list all depths tfdiJjerent(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 ofeasing: 3a tt. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifsrater level is above casing,use"+^ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR;Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well
uper cowry,cable, method: 24c.For Water Supply and Opeu-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct gash etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Fonn GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-20I8
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