GW1--05437_Well Construction - GW1_20230821

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1.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO DESCRtt'TION _
/� ft. 1/0ft. ,j 0
3441 A ft. ft. ;I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ilicable)
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL. -
Company Name f I ft. ! / ft. Co in. t It? di (v __.
i" y / ) ) -- IS.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well.Conslruclion Permit 1I: /0:47 5r: ��U FROM TO DIAMETER THICKNESS MATERIAL ----
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in. -_-i
3.Well Use(check well use): ft. ft. in. --
1
7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothennal(Heating/Cooling Supply) esidcntial Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IE.GROUT
❑irrigation ❑Wells> 100,000 GPD FROSt TO MATERIAL EMPLACEMENT SIE'1'iIOD&AMOUNT_
Non-Water Supply Well: G ft. Z U ft. 1 ,`� t ,- -, -
❑Monitoring ❑Recovery ft. ft. 1 y
Injection Well: •
ft. ft. ...
❑Aquifer Recharge ❑Groundwater Rcmcdiation
-
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD _._-
OAquifer Test ❑StormwaterDrainage ft. ft. .
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) -I
FROM '1'O 0ESCR IP'1'ION(color,hardness,soil/rock type,grabs size,etc.)
❑Geothermal(1•leating/Cooling Return) ❑Other(explain under 1121 Remarks) it. Z ft. S
�^ / ( 1
4.Date Well(s)Completed: ) /z-a 3 Well IDk :Z ft. l�U ft. C 1 C� I -...1
ft. 1� ft. e/jz r.�
5a.Well Location: w 0 S S i, .
L-C4 ) ft. ft. \ E i 1 / 1
Facility/Owoer Name Facility IDIt(if applicable) it. ft.
Z�/2\ iC,r lc A, ,-:.( A 2 R�SIr
(AL ft. ft. AN] 2 1 20Z
Physical Address,City,and Zip fa. ft.
rf`s�::fA"3ii^n Jr•���
t f 21.REMARKS erki
LYNC+�
h��` Used hardened steel drive shoe.
County Parcel Identification No.(PIN) --
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certilicati
� . '�-61Ilv�i N 1$ ��7 V� N' 5-r z -z3.
6.'spire)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this firm.1 hereby certify then the walks)was(were)constructed in accordance.a iti e
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ca:r
If this is a repair,fill out known well construction information and explain the stature of the of this record he,.,been provided to the well owner.
repair under 821 remarks section or on the back of this forms.
23.Site diagram or additional well details:
8.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction inc.:.
(add'Sec Over'in Remarks Box).You may also attach additional pages if necessar .
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:t 24.SUBMITTAL INSTRUCTIONS
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9.'fatal well depth below land surface: ! Gr '-S' (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3«200'and 2 u)00')
24a. For All Wells: Original form to Division of Water Resources (DW)C.1,
10.Static water level below top of casing: U (ft•) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+
24b. For Injection Wells: Copy to DWR, Underground Injection Control (lLls
11.Borehole diameter: 6 (it.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction meth od: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to tlto
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCU-..
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BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) V Method of test:
13b.Disinfection type: HTH
Amount: 1 lb.
Fonts OW-I North Carolina Dcparuncnt of Environmental Quality-Division of Water Resources Revised 6-6-20 t:i