GW1-2021-07202_Well Construction - GW1_20211006

1.Well Contractor Information: I e ��-� I
Landon Phillips 14r'WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
3441 A it. I ft. 15
ft, ft.
NC Well Contractor Certification Number 1&OUTER CASING'formulti-cased'wens OR LINER if An licable
N.W. Poole Well & Pump Co. FROM To DIA TER THICKNESS MATE
xIAI
I ft. ft. in. t d ^h vri►uc�
Company Name ';16.INNER CASING.OR TUBING 'eothermal closed-loo
2.Well Construction Permit#: f �D_ �' 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. in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni ipal/Public ft. ft. in..
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) tt. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18;GROUT• ."
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
f) � Q NO,Iv
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
,19 SAND/GRAVEL PACK'if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20'DRILLING LOG attach�additional`sheets if necessa '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soit/rock type,grain size,etc
4.Date Well(s)Completed: / Zv^Z Well ID# `r ft. ;l L tt. �Z, C.A
LJ Von
5a.Well Location: L - 11 ram^ '.1-C
�� 1�� ��(.✓ t!1 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2 —1 hG- !� i-_,
J� I / 5�D f 4 5�' n J 06L CJ SfD f A 4 1''�pe N fa
L ft. 5gln
Physical Address,City,and Zip 2M ft. tt. ,fir 1pC! SgC,s!
/(I 21r REMARKS
County Parcel Idendfication No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificati
6.Is(are)the well(s): e,.anent or ❑Temporary Si ature of Certified 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: Dyes or tM"o 15A NCAC 01C.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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Zv (ft.)
For multiple wells list all depths ifeli ferent(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: 2 o (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: w' I 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
aa J Program,1611 MSC,Raleigh,NC 27699-1611
'
13a.Yield(gpm) � Method of test: Permit U 1Q Gc.J
13b.Disinfection type: 4 T H Amount: I L�