GW1--05505_Well Construction - GW1_20230825

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1.Well Contractor Information: i
Landon Phillips 14.WATERZONES I •
FROM TO DESCRIPTIONINI _
Well Contractor Name 5G ft. dO ft. ZI 1 �M
3441A QC J •
ft. ft. I I _
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(ifap licable) •
NW Poole Well and Pump Company FROM TO DIAMETER i THICKNESS 1 MATERIAL _
fL ft. in.i
Company Name ,,w-- II Q ? I'S:INNER CASING OR TUBING(geothermal closed-loop) •
•
2.We11.Construction Permit#: 6.� - o T O I is'zo 2/ FROM TO DIAMETER I ! THICKNESS MATERIAL --
List all applicable we!l construction permits(i.e.UIC,County,State,Variance,etc.)
ft. fL I
ft. ft. dn..
3.Well Use(check well use): -
17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothennal(Heating/Cooling Supply) k.esidential Water Supply(single) ft. ft. in. ; -I
❑Industrial/Commercial --❑`\Residential Water Supply(shared) •
18•GROUT 1n
❑Irrigation ❑Wells>100,000 GPD FROM '1'0 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. It.
❑Monitoring ❑Recovery ft. ft. _ ""l
Injection Well: fL ft. '
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type.grain size.etc.) i
❑Geothermal(Heating/Cooling
Return) ❑Other(explain under 1121 Remarks) I At?s fL 3oS ft. '1Z _9p�
4.Date Well(s)Completed: �.]-3'"?3 Well ID/4ft' ft. !
ft. ft. I, Fo l'itE Li
5a.Well Location: tt, ft. •••
• L)IISe( Be ff(-C
ft. ft. AUGy D 5 Zd23
Facility/Owner Name Facility IDA(if applicable) I AUG ll
2. Swtk i4)h ftk._ OCJ t ie-l11`fh t-dc,/C ft. ft. •
Is v'"",..3, �z'` ea I-.'.l'
Y City, Zip NC a '1s�s ft, ft. fG;ut
Physical Address,Ci and
21.REMARKS I
V�J Je� Used hardened steel drive shoe.
County Parcel Identification No.(PIN) -'
!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,
el
onelat/long is sufficient) � h �j�j 22.Certif tali :
1 - 1-I 1-1- 5QV J N . d /1 v �/ W
6.Is(are)the well(s): i�Permanent or ❑Temporary
Signature of Certified Well Contractor Date
�`/e By signing this firm,I hereby cent&that the well(s)was(were)constructed in accordance a with
7.Is this a repair to an existing well: [ Yes or It No ISA NCAC 02C.0100 or 15A NCAC 02C.0200!Veil Construction Standards and that a corn
If this is a repair,fill out known well construed° in rotation and explain the nature of the of this record has been provided to the well!owner.
repair wider 1121 remarks section or on the hack of this form. 23.Site diagram or additional well details:
8.For GeoprobclDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:I 24.SUBMITTAL INSTRUCTIONS
i
9.Total 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((different(example-3@200'and 2@100') i
2,�� 24a. For All Wells: Original forin to Division of Water Resources (D\V(t),
10.Static water level below top of casing: (J (fL) 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(WC)
11.Borehole diameter: 6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary , 24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to tlr..
(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 o ter 100,000 GPD:Copy to DWR,CCPCUA.
IBLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb. '
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6'2tt t t: