GW1-2022-03546_Well Construction - GW1_20220322

1.Well Contractor Information: I I
Landon Phillips
''14:WATER ZONES •j;:
Well Contractor Name FROM TO I DESCRIPTION
3441 A 16 5 ft. o PM
rt. ft.
NC Well Contractor Certification Number
15.OUTER'CASING for multi-cased wells)OR LINER if a `licable
N.W. Poole Well & Pump Co. FROM TO DIAMETER I THICKNESS MATERIAL
Company Name �"` ft• bQ ft. I in. Ii G I v M1
&INNER CASING:OR'TUBING 'eothermal closed-loo`
2.Well Construction Permit#: L_Lu — o 66 FROM I To DIAMETER I THICKNESS I 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 I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) �tesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ;18;GROUT
❑lrrlation ❑Wells>100,000GPD FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. p ft. Q
❑Monitoring ❑Recovery
Injection Well:
ft.
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK if a Gcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach'iidditional"sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,eta
0 ft. 2 ft. 'T6 12 C,
4.Date Well(s)Completed: --r? _2 Well ID# Z ft. S5 ft.
5a.Well Location: j ft. ft.
POA/1 i Ie +h0me5Un rt. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/ 4 7-
120 �/ 2�' �r 5 A �N� a 7J2� ft. rt. iy ; . . ..
Physical Address,City,and Zip ft. ft. MAR '
G..I(,- 21.:PEMARKS`";,
County Parcel Identification No.(PIN) Used hardened steel drive shoe_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "
(if wellfield,one lat/long is sufficient) 22.Certification:
log U—Ti N ^�" 'SUI '1 W �6.
Is(are)the well(s): ermanent or ❑Temporary elue e Contractor Date
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: ❑Yes or ex/o I5A NCAC 02C.0100 or I5A 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: j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3d 0 ft.
For multiple wells list all depths ifdii 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: 20 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: v (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
�j Program,1636 MSC,Raleigh,NC 27699-1636
12•Well construction cation method, _ 4 C3 f t� 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) /
/U Method of test: 'o ( Permit Program, 1611 MSC,Raleigh,'NC 27699-1611
13b.Disinfection type: ! Amount: f' '/