GW1-2022-06744_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3441 A o ft. 02 ft. 3 M
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER(if a livable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS aATERIAL
rt. rt. in• k I�r
Company Name
16.INNER CA ING OR TUBING eother'm closed-too
2.Well Construction Permit#: WSJ" NC't
/�0,;q 0I�)_0 FROM I TO DIAMETER TWCKNESS MATERIAL
List all applicable well construction permits Q.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): tt. tt. io.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in
hidustrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
❑IRI ahon ❑Wells>100,000 GPD FROM I TO MATERIAL EM CEME MTHOD&AMOUNT
Non-Water Supply Well: ft. It. ' !m
❑Monitoring ❑Recovery ft. tt:
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if a ltcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EIIIPLACEMENT 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color hardness soiVrock e, rain size etc.)
ft. It.
4.Date Well(s)Completed: "a 7-2 Z Well ID# ft. ft.
t
5a.Well Location: ft. O t. rNr��t..
rj }C t C>t�Cei I De oAL(e\/hens ft. IL a OF
Facility/Owner Name Facility 1139(if applicable) ft. ft.
Z( No rfk,r^ F"l/S P-ef- d-is rJC-C_JCV_1,_ ft.
Physical Address,City,a d Ip ft. ft.
r n?�
gahvi
.. 21.REA ARKS .'i=,v . 16Z
--J, .en o,
ZEW Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one
fat/long is sufficient) 22.CertiflCa' t: u
(00l{ I. J N _79 of�1 1 4:7, r2 W — I —a7—Z e-
s
6.ls(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certtty that the irell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Nell Construction Standards and that a cop),
!(this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under P21 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d S (rt.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifoli ferent(example-3@100'and 1@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10,Static water level below top of casing: 2-6��(( (h) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!J"irater tenet is above casing,use"+"
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR;Underground Injection Control(TUC)
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 producing:over 100,000 GPD:Copy to DWR,CCPCUA
BIOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 13 Method of test:
HTH 1 lb.
13b.Disinfection type: Amount:
k
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019