GW1--05435_Well Construction - GW1_20230821

1.Well Contractor Information: 4.. 4)/2 •
Landon Phillips I4.WATER ZONES
Well Contruclor Noose FROM TO DESCRIPTION -1
?S ft. ft. a 6
3441 A ft. ft. '�
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if op aicable)
NW Poole Well and Pump Company FROM TO DIAMETER TIHICK-NESS MATERIAL
f i ft. 6 t0 ft. Co in, t/( /7 .67&t I v _.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well.Construction Permit ii:4 eE-S Z?/z 'CO 7(1
FROM TO DIAMETER THICKNESS MATERIAL ____
List all applicable well cansiructlort permits(i.e.U1C,County,Slate, Varlance,etc.) ft. ft. in. _
ft. ft. in.
3.Well Use(check well use): _..
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE '1•IIICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
OGeothennal(Heating/Cooling Supply) fISgesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial /❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL//'' EMPLACEMENT METHOD St AMOUNT._
Non-Water Supply Well: C) It. Z U ft. �SPit'1trl 1 F� pLl r- --____
OMonitoring ❑Recovery ft. ft.
Injection Well: •
•
ft. ft
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT Rf ET/IOD �_I
OAqui ter Test ❑Stormwater Drainage ft. ft. • _`
OExperimental Technology ❑Subsidence Control ft. ft.
- _i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROiSt TO DESCR IP•I•fON(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) ft. Z ft. n Spl /
4.Date Well(s)Completed: I/-73 Well ID", Z ft. co ft. lri.f ...I
5a.Well Location: .s-- ft.3CDs"- ft. _Lrii P rl/ , r4 ate' E-1
ft. IL
/ ;/t'1e IR &i AI% C . AUG 1 1 _-
Facility/Owner Name Facility IDII(if applicable) ft. ft
Q� 3 ft. ft. 2oZ3
?(/ /1�n.,(e Li I't ur,1 /1C �V tr t;-..r:t^4k<�n PI^A. •61 ert..i
Physical Address,City,and Zip IL It.
Qrfi A^'..'I11i 1
21.REMARKS _I
lci.,n r
County Parcel Identification No.(PIN) Used hardened steel drive shoe. ,
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la/long is sufficient) 22.Certificali .
. '25 I vb N "lib• (.2 SI, W 5--1,_z 3
6.ls(nre)the well(s): OPcnnancnt or OTemporary Signature of Certified Well Contractor �` Date
By signing thi.rform.1 hereby certify that the walks)inns(were)constructed in accordance vita
7.Is this a repair to an existing well: ❑Yes or ONo !SA NCAC 02C.0100 or 15.1 NC.IC 02C.0200 IVell Construction Standards and that a fin,.•,
If this is a repair,fill out known tie!!construction information and explain the nature of the odds record has been prnt•ided to the well an tter.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/UPT 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
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9.Total well depth below land surface: / ( . (ft.)
For multiple trolls list all depths if different(example-3 r@200'and 2 n 100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWl.),
10.Static water level below top of casing: Z ' (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 (ILIC:
1 I,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 ill.;
(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,CCPCUr..
BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) z G Method of test: '
13b.Disinfection type: HTH Amount: 1 lb.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 I: