GW1-2022-06406_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZOxFS
Well Contractor Name -FROM TO I DESCRIPTION
3441 A "' 6 " f rn
rt. rr.
NC Well Contractor Certification Number
.15.OUTER CASING for multi-cased wells)OR LINER if a licable
NW Poole Well and Pump Company FROMI TO D ETER TIIICFCNESS M1AT .,
Company Name It( ft.
ft. e,
/y-• '-G
v 1 1 _ O t� �0, 16.INNER CASING OR TUBING eothermnl closed-loo
2.Well Construction Permit#: Vl/ FRO51 TO DIAMETER THICKNESS MATERIAL
Lis(all applicable well construction permits(i.e.UIC,Camay,State,Variance,etc.) ft• ft. in.
3.Well Use(checil well use): ft. rt. in.
Water Supply Well: 17;SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic n• n• in.
❑Geothermal(Heating/Cooling Supply) gIResidential Water Supply(single) ft. ft. in.
❑bidustriai/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi atioll ❑Wells>100,000 GPD FROM I TO MI TERIAL EMIPLAC LENT METHOD&AMOUNT
Nou-Water Supply Well: ft. J0 ft. /(t
❑Monitoring ❑Recovery ft. tt. Y
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if a lkable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMIPLACEMIENT METHOD
❑Aquifer Test ❑Stormwater Drainage 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 soil/Irack e, rain size,etc.)
❑Geotllennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d ft. it. � !� rI C
4.Date Well(s)Completed: —0 Z Z Well ID# ft. tt.
5a.Well Location: it. ��
p+C, ?G�n-L ft. %
Fa it ty/Owner Name Facility ID#(if applicable) ft. ft.
ft. fL
Physical Address,City,and hp ft. ft.
// tt _
a -75T7 4 9
21:REMARKS
County Parcel Identification No.(PIN) 202?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t3ita'r, ,` ;bra
(ifwell field,one
lalat/lofnggiis sufficient) <_ 22.Certifica ,'
N .�/✓ -OV� t ivil511(�r� 'C�� L�7 i1Si)ICII
W
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo ISA NCAC 01C.0100 or I5A NCAC 01C.0100 If'ell Construction Standards and that a copy
Ijthls is a repair,fill out known well construction h jonnation and explain the nature ofthe ofthis record has been provided to the well owner.
repair under P21 remarks section a•on the back ofthis fonn.
23.Site diagram or additionalwell 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 h)fo
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 '3 C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
Por multiple wells list all depths ifdierent(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 of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfhraler•level is above casing,use'+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1.1.Borehole diameter: � (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12,Well
uger Gouty,cable, 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 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: BIQW Permit Program,1611.MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH. Amount: 1 lb.
Forst GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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