GW1-2022-06402_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips .14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3441 A
NC Well Contractor Certification Number 15:OUTER CASING for multi-cased wells OR LINER if i licable
NW Poole Well and Pump Company FROM TO DL1AfETER THICKNESS MATERIAL
ft. ft. in.
Company Name ft.
O�I d..��I 16.INNER CASING OR.TUBING(geothermal closed-loop)
2.Well Construction Permit tl: c� FROM TO DIAMETER TinCKNESS MATERIAL
List all applicable;vell construction permits(i.e.WC,Coun(K State,Parlance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREE TO DIAMETER SLOT SIZE THICIflYESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) g-
>hldustrial/Commercial ❑Residential Water Supply(shared) :18.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EAIPLACEAIENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EAfPLACEMENTAIETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21'Remarks) FROM .TO DESCRIPTION color,hardness soll/rack type,fwdn Size etc.)
IRS u. 84 ft. RAArIT,E
4.Date Well(s)Completed:4 13 a?--Well ID# ft. ft.
' ft. ft.
Sa.Well Location: P
C/fPi�IAG �GritDq ft. rt
Facility/Owner Name Facility ID#(if applicable) ft. ft. J U 3 '
7 t je r Si —R s /e h' ft. ft.
S r::m eI�F�11
Physical Address,City,and Zip ff. ft. �j�si i:; r ',t
1e1�9 vw 11.REMARKS G v':f�lr0lr it i i1 'JL�VTII'1^ i
County Parcel.Identification No.(PIN) DR tl r
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: R C �Z A & ZV40
(if well field,one lat/rloonng is sufficient) ^� ' `, / �(� ^� '22.Certifies'
3"5 -_Iq l 1 t(J N '� 1�' `'��� 1 `� W �J
CPO
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor D e
By signing this forni,I hereby certify that the svell(s)etas(mere)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or ©No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'ihis is a repair,fill out known smell construction it jor•mation and explain the nature ofthe ofthis record has been provided to the well ouver.
repair wider#21 remarks section or on the back of this 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-1 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:_ Q. (ft.) Submit this GW-1 within 30 days of well completion per the following:
For-nnrltiple;cells list all depths ifdierent(example-3@200'and 2@I00)
24a. For All Wells: Original.form to Division of Water Resources (DWR),
10.Static water level below top of casing:—(h•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifmater level is above casing,use"+"
24b.For Injection Wells:Copy to DWR;Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
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 WELLS ONLY: 24d.For Water Wells producine over'00,000 GPD:Copy to DWR,CCPCUA
^^�� BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) dV � Method of test:
13b.Disinfection type: HTH Amount: 1 lb. j
r
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018