GW1--05510_Well Construction - GW1_20230825

I V IJ1JAS V V t I V a as la V a a V A I a V-•V v a•.✓ t V •I o f , J. •...v,,.u,V.,v...sit,-
1.Well Contractor Information: '
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Landon Phillips 14.WATER ZONES I i • • ' _I
Well Contractor Name FROM TO DESCRIPTION
s 5 ft. /O//Q ft. 1 ✓ ,% y0r�
3441 A ft. ft. • '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased well's)OR LINER(if ap dicable)
NW Poole Well and Pump Company FROM TO DIAMETER' 1 THICKNESS MATERIAL
+/ ft. ..b 7 ft. . I in} • If S 74.(0.,•`t.0
Company Name • 70-6 16.INNER CASING OR TUBING(geothermal closed-loop) • • •
2.Wcll.Construction Permit II: lJ'1� _O5. -zO ai FROM TO- DIAMETER ' TIIICKNESS MATERIAL __
List all applicable hell construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. :in. ~1
ft. ft. ;in:
3.Well Use(check well use):
Water Supply 17.SCREEN
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL __I
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Pleating/Cooling Supply) )(Residential Water Supply(single) ft, ft, in,
❑Industrial/Commercial ❑Residential Water Supply(shared) •
IS.GROUT -
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL' EMPLACEMENT MGI'roo&AMOUNT_
Non-Water Supply Well: O rt. C� rt. (g iec p/l� i v v� -�?
❑Monitoring ❑Recovery , ft. ft. 1�� ✓J
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmediation 10.SAND/GRAVEL PACK(if applicable)
oAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETt10D ___
❑Aquifer Test ❑Stormwater Drainage ft. ft. _. •
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothennal(Closed Loop) OTracer 20.DRILLING LOG(attach additional Sheets if necessary)
FROM TO DESCRIPTION(color,har ss,dne soil/rock type,grain size.etc.) -_I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) R ft. T P w/'L
4.Date Well(s)Completed: -5-g"Z-•) Well IDH a ft. L/ ft. CIS V i
5a.Well Location: �A pt -I, r 20 d' f M ;i r
Facility/Owner Name / Facility 1DA(ifapplicable) ft A I I(� 2 ��y L1I2'�
o 1C i l b y r n �c'. 1 C.ct,f.e f I /1/C• fa 7 `_( ft. ft. Fi lJ u 1
Physical Address,City,and Zip ft. ft. Infora'Sa rCil Pr a'r 'fJ h;flii
1A)(it( _ 21.REMARKS I :vOJ O -I
V Used hardened steel drive shoe. -I
County Parcel Identification No.(l'tN) - 1
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) . 22.Certificali , •
I
N ) w
S-f-z
6.ls(are)the well(s): ❑Permanent or OTemporary
Signature of Certified Well'Contractor -i W Date
0y signing this firm.I hereby certify that the 11,e/1(s)was(mere)constructed in accordance wit?,
7.Is this a repair to an existing well: ❑Yes or inNo Jul NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and thin a cc,
if this is a repair,full out known well construction information and explain the nature o/'the of this record has been provided to the well'owuer.
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprohc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction inro
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You'may also attach additional pages if necessar:!.
drilled:t 24.SUBMITTAL INSTRUCTIONS
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9.T otal well depth below land surface: (It.) Submit this GW-1 within 30 days of well completion per the following:
'For multiple wells list all depths if different(example-3 n 200'and 2 a 100')
24a. For All Wells: Original form' to Division of Water Resources (DW0.),
10.Static water level below top of casing: 2a (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to I�WR, Underground Injection Control(MCI11.Borehole diameter: 6 (in•) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to Eire
• (i.e.auger,rotary,cable,direct push,etc,) county environmental health departmcntiof 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,CCPCUr..
BLOW Permit Program,161 I MSC,RRleigh,lNC 27699-1 6 1 1
13a.Yield(gptn) I Method of test: 44
13b.Disinfection type: HTH Amount:
1 lb.
Form GW-I North Carolina Deparunent of Environmental Quality-Division of Water Resources Revised 6-6-20 i ti