GW1-2022-06401_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14;WATER ZONES
KFROIMITO DESCRIPTION
Well Contractor Name f.3441 A
io ft &^
NC Well Contractor Cerification Number CA G for mul -cased wells OR LINER if a licablcNW Poole Well and Pump Company TO DIAIVIETEA THICKNESS 11fATERIAL
It. L tt. t-it
Company Name �U- 16.INNER CASING OR TUBING eothermal closed-loo 'C2.Well ConstructionPermit#:( 07/c l —2O 2 FROM TO DIAMETER THHCKNESS MATERIAL
Lint all applicable well construction perPinits(i.e.WC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(cliecic well use): ft. ft. in.
EEN.
Water SupplyWell: FROM
TO DIAIVSETEA SLOT SIZE Tf1iC[QVESS a1ATERLiL
❑Agricultural ❑Municipal/Public. ft.. ft. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 77ii.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM I TO 11I TERIAL EMPLACEMENT 51ETIIOD&AMOUNT
Nou-Water Supply Well: ft. ft. G�
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO51 TO MATERIAL EIIIPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage , ft. it.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
zf
.TO DESCRIPTION color,hardness,soil rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft.
9 i�
4.Date Well(s)Completed: -�d -ZL Well IDN I. r
5a.Well Location: fp GU A S QSft.A4tls= it
Facility/Owner Name Facility lD#(if applicable) ft. ft. t I •r. 3,, do '
SR(3 V i rNtYc n�k Ln PJ 1ei4 0 ft. ft. IkI
c ft. ft.
Julli us
Physical Address,City,and Zip ') ?(-I3
r v� 21.REMARKS
Cl.b� i lJ ti awn ' 1„
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/l(onggis sufficient) 22.Certificat'
Signature of Certified Well Contractor Date
6.Is(are)tlnewcll(s): ®Permanent or ❑Temporary -
By signing this form,Lhereby certify that the svell(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15ANCAC 02C.0100 or ISANCAC 02C.0200 Nell Construction Standards and that a copy
\/this is a repair,fill out known well construction information and explain die nature ofthe ofthis record has beenprovided to the well owner.
repair under il21 remarks section or on the back ojthis forn. 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 c 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60 1 (It') Submit this GW-1 within 30 days of well completion per the following:
For nndtiple wells list all depths ifdierent(exannple-3@200'and 2 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top as[Dg: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ljwater lanai is above casing,use"+'
1.1.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Supply and Open-Loon 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 SUPPL ELLS ONLY: 24d.For Water Wells producine river 100,000 GPD:.Copy to DWR,CCPCUA
Blow Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Fortn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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