GW1--05432_Well Construction - GW1_20230821

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I.Well Contractor Information: -__
Landon Phillips _�
•14.WATER ZONES .
FROM TO DESCRIPTION
Well Contmctor Name ft. kr S ft. 5`
ft. ft. '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) •
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIALAT -
r t ft. l.Q 3 ft. (O in. //.7 l41/
Company Name r ••
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well,Construction Permit#: 1.....2. 3 -DCVO I&A. FROM TO DIAMETER TIHCKNESS MATERIAL --
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc) ft. ft. to --
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothennal(Heating/Cooling Supply) 1Isidential Water Supply(single) ft ft. in. _
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2-0 ft. ,cn fG,' 1,1 �n�,
❑Monitoring ❑Recovery ft. ft. �
Injection Well: ._--.
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation --•
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO DATERIAL EMPLACEMENT METHOD -
❑AquiferTest ❑StormwaterDrainage • ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft I
I
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sait/rock ll ypi,Aratn�sizc°ctc�' 0 f j"�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) G rt. rc.' f on I t i q-�p 1.... , {�.✓3
4.Date Well(s)Completed:6/-o I/ -e2 3 Well ID# .Os ft. L/O ft. .c" ex 1 AUG 2 1..11023
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•
5a.Well Location: L(0 ft. . ds-- ft. 611 erne( I
• (Q� �) ft. ft- rervvrr our r ''fd'.dtruri U11.1
/7✓1 e L "1/Gtcal S , 1
1
Facility/Owner Name Facility IDII(if applicable) /y�� I, ft. ft.
l fit l,, i' 2 f(/I Le ft. ft.
•
�a� �� �Ctlr� ✓�l�/� �,� LGi' C� 1�
Physical Address,City,and Zip u' ft. ft. • I
21.REMARKS �l
44 C'II -I
County Parcel IdentifIcntion No.(PIN) Used hardened steel drive shoe. i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -I
(ifwell field,one lat/long is sufficient) 22.Certificati .
.oSZ�� N 7�. 01, �+�- W �� q-24--z3
6.ls(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)alas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or In No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a c .
If-this is a repair,full 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 back of this form.
23.Site diagram or additional well details:
S.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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessar}.
drilled:I 24.SUBMITTAL INSTRUCTIONS
9.T oral well depth below land surface: _2°S (ft) Submit this GW-1 within 30 days of well completion per the following:
'For multiple wells list all depths if different(example-3@200•and 2(4t)100')
10.Static water level below top of casing: (2U (fe) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Infection Wells: Copy to DWR, Underground Injection Control(1UC)
11.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 117c
(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 over 100,000 GPD:Copy to DWR,CCPCU,..
13a.Yield(gpm) 5.-' Method of test:
BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-20 I d