GW1-2021-07206_Well Construction - GW1_20211006

1.Well Contractor Information:
Landon Phillips 14:'WATERZONES. .
Well Contractor Name FROM TO DESCRIPTION
3441 A tr36 ft. 23 ft. 2_�o in
ft. ft.
NC Well Contractor Certification Number 15.'OUTER;CASING foe multi-casedswens OR LINER if a livable
N.W. Poole Well & Pump Co. FROM TO DIA
METER TIDT ESS MATERIAL
Company Name _tL ft. I ff ft. I Z in. I ; 16- I wvIn01
516 INNER CASING OR:TUBING. eothetmal closed-llio" -
2.Well Construction Permit#:. V 60 l_�® 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: 171 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) URz<dential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18;GROUT,
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. 270 tt. O War
❑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 MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20:DRILLINGILOG:attach additional•sheets:ff uecessa "
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiltrock typt in sae,etc
7 D ft. 2 ft.
4.Date Well(s)Completed: `_c23_) Well ID# 2 ft. ft. C t�
5a.Well Location: y ft. ft.
M6,� -� sal w/`� ft. ft. �f
Facility/Owner Name Ci Facility ID#(if applicable) ft. ft.
RU&d ho& x/�--C
Physical Address,City,and Zip
/r/A< 21-REMARKS-
County tom\ Parcel Identification 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) ''�] j� 22.Certification:
35,el
72
6.Is(are)the weli(s): 6ermanent or ❑Temporary Sire of Certified Well Co for Date 1
� By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or W"o 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 G�V-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
f
9.Total well depth below land surface: /`-' (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 (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
' E
11.Borehole diameter: (%fLr
24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Wellconstruction method: Y 24c.For Water Supply and Open=Loop Geothermal Return Wells:Copy to the
(i.e.augerr,,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: J 24d.For Water Wells producing'over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Z t l Method of test: J Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: L