GW1--05509_Well Construction - GW1_20230825

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1.Well Contractor Information:
Landon Phillips 14.WATER ZONES • I• I ' ' • _I
Well Contractor Name FROM TO DESCRIPTION
P ft. (�(J ft. U f I
3441 A /2crt. (7 5 r. / - I
,
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-cased wells)OR LINER(if no dicnhle)
NW Poole Well and Pump Company mom TO DIAMETER I TIHCIPVESS MATERIAL .. f -
Company Name F. I ft. Cs,7 ft. G 1 tri, . //7 6,,1 I/G n t7c _.
// MANNER CASING OR TUBING(geothermal closed-loop)
2.Well.Construction Permit 0: ( "7 Ltd -06 S 7 5-0 "'2 6 .I FROM TO DIAMETER I THICKNESS MATERIAL _
/.isi all applicable well construction permits(i.e.UIC.County,State,Variance,etc) ft. ft. III. _-I
3.Well Use(check well use): ft. It. in.
17.SCREEN
Water Supply Well: FROM TO DrA111ETER SLOT SIZE ' TIIICICNESS MATERIAL _
❑Agricultural ❑Municipal/Public A. ft. M.
❑Geothermal(Heating/Cooling Supply) 9sidcntial Water Supply(single) ft. ft. in,
Olndustrial/Commercial 'OResidential Water Supply(shared) 18,GROUT
❑lrrigation ❑Wells> 100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. Co 7 ft.
d
❑Monitoring ❑Recovery ft. ft.
Injection Well: R. It.rt.
...--..
❑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.
OGeothennal(Closed Loop) ❑Trfcer 20.DRILLING LOG(attach ndditionul'shccts if necessary)
FROM •ro DESCRIPTION(color.brininess.soil/rock type,grata size,etc.) __I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) 0 ft, Z ft. (O Sot
4.Date Well(s)Completed:J-1 h Z3 Well IDIIft 4 1, -i
�/S n. /es- ft. Crcn/><d r 7.. .rR l
5a.Well Location: Vitt- 1
•acility/Owner Name Facility IDN(if applicable) ft. ft. A l l l7 p '
o / P 1 ///2J I�q leic l (7 C, ft. . ft. II Y{tyt iM jf� ..r 2023 I
y �� I
..� ft. ft. �L7 l�,..�,� i r
Physical Address.City,and Zip '��� '1'('I4
/� r 21.REMARKS -i
Up lici F5-L 1
� , e Used hardened steel drive shoe.
County Parcel Identification No.(PIN) .;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
Orwell field,one tat/long is sufficient) / 22.Certificati : •
6.Is(are)the well(s): kiPcrmmnncnt or ❑Temporary Signature of Certified Well Contractor Doc
By signing this firm,I hereby certify that the well(s)was(were)constructed In accordance a ltit
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 1Vell Construction Stamhtrds anti that a car
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 1121 remarks section or on the hack of this form.
23.Site diagram or additional well details: •
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into.construction,only 1 GW-I is needed. Indicate TOTAL NUMBER dwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:1 24.SUBMITTAL INSTRUCTIONS'
9.'Iota!well depth below land surface: (ft.) Submit this GW-1 within 30 days of,well completion per the following:
'For multiple wells list all depths If different(ecantple-3 a 200'and?a 100')
24a. For All Wells: Original form to Division of Water Resources (D\\tl:;l,
10.Static water level below top of casing: Z 6 (IL) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617'
If water level is above casing,use"4." I
24b. For Injection Wells:Copy to DWR,Underground Injection Control (MCI
11.Borehole diameter: 6 (in,) Program, 1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.c.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 ovl r400,000 GPD:Copy to DWR,CCPC1.I4.
�� BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
G 13a.Yield(gptn) . 0 Method of test: '
1 lb.
13b.Disinfection type: HTH Amount: .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-20iti