GW1-2021-07193_Well Construction - GW1_20211006

1.Well Contractor Information:'
Laudon Phillips I4.WATER ZONES
Well Contractor Name FROM TO DESCWTION
3441 A 010 S -a w ft. i /v\
nay
rt. sd Srt. 3
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ncable
N.W. Poole Well & Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
ft. ( ft. in.
Company Name
`� &INNEWCASING OR TUBING" eothermal closed=loo
2.Well Construction Permit#: I r FROM TO 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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) P(esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i8.GROUT `
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 7 U ft. { Lu
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
191 SAND/GRAVEL PACK if a licable "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer �20.�DRILLING LOG attach additionelshe6ts"if necessa'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc.
ft. 2 ft. 70, Se,J.L
4.Date Well(s)Completed: ZI Z I Well ID# 2 tt. 3C ft. C A, Y
Sa.Well Location: J b
2c�h ft-to 2&,m,,fe 2 ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4
j 2 UT 25 Ln C 1 t�-Y�V' 2 i\&
Physical Address,City,and Zip ft. ft. Q�gS
21i°REMARKS­�;., C,g
County V Parcel Identification No.(PIN) Used hardened steel driv e 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiticati
?SST a N W _Z f
6.Is(are)the well(s): V—J�m anent or ❑Temporary Si r ertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.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 well owner.
repair under#21 remarks section or on the back of this form.
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �b S (ft.
For multiple wells list all depths if dierent(example-3@200'and 1@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),
lfwater level is above casing,use"I+.^ Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C7 (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC;27699-1636
12.Well construction method: I L rY 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
13a.Yield(gpm) f' Method of test: (J(.) &V Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: b I
I