GW1--05496_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Landon Phillips t F
.14:WATERZONES.I:.•„.:7- I..I ..._ '
Well Contractor Name FROM TO DESCRIPTION
3441 A ft. rr*
tc ft. l
NC Well Contractor Certification Number I
-15.OUTER CASING(for multi-casedlwells)OR LINER-(if'an Roble)NW Poole Well and Pump Company FROM TO DIAMETER I THICKNESS 1 MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR.TUBING.(geothermal closed-loop), •
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •17 SCREEN' . •:'.G:• • -
•
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑/Agricultural ❑MunicipaVPublic ft. ft. in.
ypGeothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft ft. in
Industrial/Commercial ❑Residential Water Supply(shared) 111..GROUT., :.. -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. SOU ft' .f(„(rna,�eory Pc)l�1 P
OMonitoring ❑Recovery ft. ft. /{c J
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if rpplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑StormwaterDrainage ft. ft.' '
❑Experimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer •20 DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,Bic.)
ft. L fs.f t' C.f r L Y
4.Date Wells Completed: .�b-.1 Well ID# 45 Q
`' ' /.l
5a.Well Location: ft. ft. ! `t1�
Arr 5Ys .f.seIJiCe-5 ft. it. . I. 1C"a�1ll� 'A
Facility/Owner Name Facility ID#(if applicable) fL ft•
¶3I> •uc/ ce()ri lc( 26I,re.y h Alt- 2. 76/ 3 ft. ft. • , AUG 2 5 ZZ023 4
Physical Address,City,and Zip ft' ft. t
J EfGfAra.vrt�.,..ti n: •7 l.n�
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Ni4.Y1 t 21.REMARKS •.` .. I '. D414f.3'"r r, nr; -
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County Parcel Identification No.(PIN)
Used hardened steel drive shoe.-- t
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J
(if well field,d,one lat/long' is sufficient) �1 2.2.Ccrtifrcati
/1✓. l V-!-1 N 7�j.7 +2, w
6.Is(are)the well(s): Permanent or ❑Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the irell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cost-
If this is a repair,fill out known well construction it formation and explain the nature of the of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form. I '
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:b
©� 24.SUBMITTAL INSTRUCTIONS
9.'Total well depth below land surface: (ft) •
For multiple wells list all depths if different(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use"+'
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary ••
12.Well construction method:
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to th,=,
(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 ove i 100,000 GPD:Copy to DWR,CCPCUA
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: '
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 G
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