GW1-2022-06408_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14i WATER ZONES
Well Contractor Name FROM TO DESCmPTION
3441 A 0 ft 0 S ft. 9 a ` Ply.
NC Well Contractor Certification Number / o ft. `/�' ft /d P �
15i OUTER CAff99SING for multi-cased wells OR LINER if a livable
NW Poole Well and Pump Company FROf1I TO D TEA THICKNESS MATERIAL. .
ft. s... ft. in. - 1 IF tt,t ul
Company Name .16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: V v SS'L� L�? FROM TO DIAMETER I TIUCKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,Counry,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. 1°
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TIHCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
❑hidustrial/Cominercial ❑Residential Water Supply(shared) IS,:GROUT
❑Irrl atiotl ❑Wells>100,000 GPD FROM I TO ARTERIAL E51PLACE51ENT METHOD&AMOUNT -
Non-Water Supply Well: ft. ft. /� �J/ ✓�
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEMAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color hardness soill ock type,grain size,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: Well ID# J ft. Cf
ft. �-
5a.Well Location: G it I . ft.
old tier Ic avt(&5- ft.. M _
' Facility/Owner Name Facility ID#(i£applicable) ft. ft. ,��� r�.,r �„
1 � n
6a o I ' Jlct� _S`C t 2 f. -�, C Lk ft. ft.
Physical Address,City,and Zip - eraSd ///a'C� p ft. ft. ` ti
n jr, I/. a 70 F..7 2L REbIARKs t r._
V I/W`'L f2i Y'i V: J l llifI
County Parcel Identification No.(PIN) tear° �•e w nr�nnr n.,n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iflvell field,one lat/long is sufficient) r ( � 22.�11 • :
N � I (©W 'tom W 3 —2 �—"2 2
•s �J
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature o£Certified Well Contractor Date
By signing this form,I hereby ceri fy drat the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the vvell ouvrer.
repair under#21 remarks section or•on the back of Ads jornr.
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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /�� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple irells list all depths ifd fferent(example-3 a200'and 2@100) y p p g'
10.Static water level below top of casing: Z t✓ (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"i 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 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 WI
iLLS ONLY: 24d.For Water Wells producinz over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 2 V Method of test: Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018