GW1-2022-06407_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon"Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3441 A NOft. ft. _
ft. ft.
NC Well Contractor Certification Number M OUTER CASING for multi-cased wells OR LINER if li a cable
NW Poole Well M and Pump Company FROj ft. TO ft.
t DIAMETERtn TIHCKNESS hATERIAL
Company Name
G X (_7v2- 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 6-��J-L)`�//� t t� /CJ V FRO51 I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN. .'
FROM TO DIAMETER SLOT SIZE TfHCKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) )(Residential Water Supply(single) ft. ft. ;a
❑Industrial/Commercial /❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO h ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft• ft. s ✓(��/
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge El Groundwater Remediation
=19.SAND/GRAVEL PACK if applicable)
OFT
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERrAI, EMPLACEMENT MET-ROD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attach additional sheets if necessary)
FROM. TO DESCRIPTION color,hardness soilfrack e, rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
Mee
4.Date Well(s)Coinpleted:/22-o2_22 WellIDIf ft. ft. n
n
5a.Well Location: GC.1�ft.
ft. re
Facility/Owuer Name Facility ID#(if applicable) ft. ft.
Wv tool( W�,,ylc-(�f'ly-)7s21 ft. ft.
Physical Address,City,and Zip ft. ft.. �n
GL47-
2L REMARKS.
County Parcel Identification No.(PIN) i
ti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
et.�10-IT11n
(if well field,one IaUlong is sufficient) 22.Certifica� _�Ca*i a:+5v 1 flE
2J5 � � D� N I 0 (p.t W Pf E_ �0 UNIF
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor ` Date
By signing this form,I hereby cert fy dirt the ivell(s)was(were)constructed in accordance irith
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known ivel/construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 921 retnarks section or on the back ofthis fornn
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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U (ft.) Submit this GW-i within 30 days of well completion per the following:
Fo•multiple hells list all depths tf different(example-3@200'and 2@I00)
10.Static water level below top of casing: 2-6 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lI.Borehole diameter (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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)AWLLS ONLY: 24d.For Water Wells producint over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) (w Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Ib.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I