GW1--05475_Well Construction - GW1_20230821

1.Well Contractor Information:
Landon Phillips .14.WATER ZONES. • . , . -�
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3441A 'it. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if opllicable) •
NW Poole Well and Pump Company FROM TO DIAMETER I I THICKNESS I MATERIAL _
ft. ft. 1
n.1
Company Name •
16.INNER CASING OR TUBING(geod:ernial closed-loop) . , •
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL --
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Q) ft- 3Z S ft' m. .sc(/?"'I) ?V _
3.Well Use(check well use): ft. R. in. I
Water Supply 17.SCREEN
PP Y Well: FROM TO DIAMETER SLOT SIZE ff[[CICNESS t MATERIAL _j
❑Agricultural ❑Municipal/Public ft. ft. in. .Jrr ...
XGeothennal(Heating/Cooling Supply) i lResidential 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: U ft. 3z.5 ft. i3 k y ,j PU('1 7" -I
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. . ft,
❑Aquifer Recharge ❑Groundwater Remediation ---
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHIOD .....
❑AquiferTest ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. I
OGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size.etc.) _
❑Geothermal(Heating/Cooling ❑Other(explain under#21 Remarks) 0 ft. �)c� ft p © L _11
4.Date Well(s)Completed: 3 `�O-Z-S Well ID# . 7 ft. L j ft. LT/ /
5a.Well Location: - CI 3 ft. )a' ft. f,r( , .)1 61-/(_
ft. ft.
• A i c 5/S-i-e tit Se rrU,6--5 �''�y__QQ r--; �f r.
Facility/Owner Name Facility IDIl(if applicable) ft. ft. li ®�O.o lL i V C ;
SSS Ala, ilv(c cAofc.A i)r( / (2c( AiL a752? ft. ft. AIJC g 1 2023 -a
ft. ft. n
Physical Address,City,and Zip •
(� 21.REMARKS Ire f (I f1 i''rAtS�i�rwl 1:tay
I 1 ��� I Isere hardened-steel-dff+re ez:-'DWQMCW3 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certiftcati
5. tla11-1- N 7€. g555O W -e________� 3-o - 23
,,,1 Signature of Certified Well Contractor Date
6.ls(are)the well(s): &iPcrmanent or ❑'temporary
ff+V�1VW11 ����....!!!!_�'''' By signing this form,I hereby cerr&that the well(s)was(were)constructed of accordance with
. 7.Is this a repair to an existing well: ❑Yes or ,(No ISA NCAC 02C.0100 or iSA NCAC 02C.0200!Veil Construction Standards and that a cow
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 back of this form. 23.Site diagram or additional well details:
6.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction iirt;,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovei'in Remarks Box).You may also attach additional pages if necessary.
drilled:1.- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 2,5 (It) •
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@I00')
24a. For All Wells: Original form to Division of Water Resources (D\\tic),
10.Static water level below top of casing: (IL) 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 (IUC)
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 that
(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 -
------ - BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6--20