GW1--05506_Well Construction - GW1_20230825

Y1 L'IJ1J 1.V111J.LL J%J 11V111tit.ViW IV tr-it ivi ii.wiiiui v....v. - I
1.Well Contractor Information:
Landon Phillips Ia.WATER ZONES 1 ' _.t
Well Contractor Nome FROM TO DESCRIPTION'
3441A mU ft. (9/g- ft. 7 1
ft. ft. k
NC Well Contractor Certification Number -
15.OUTER CASING(for multi-cased wells)OR LINER(if np tlicnble)
NW Poole Well and Pump Company FROM TO n1AMETERI ! THICKNESS MATERIAL I1
}" l ft. �13 ft. CO lint . )(? �.t\\t/lt7del1_.
Company Name /', l -, 16.INNER CASING OR TUBING(geothermal closed-loop) - • ' _ _
2.Well.Construction Permit4:6 C w�1 DZiL) -Go2 Z.- FROM TO DIAMETER I THICKNESS MATERIAL --
List all applicable well construction permits(i.e.UIC,County,State. Variance.etc.) ft. ft. nut. __I
ft. ft. in.
3.Well Use(check well use):
-
t7.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIIICIWESS MATERIAL _-
❑Agricultural ❑Municipal/Public ft. ft. in.
•
❑Geotllennal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial OResidential Water Supply(shared) 10.GROUT
❑irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EsIPLACEMENT METHOD&AMOUNT_
Nan-Water Supply Well: G ft. 2 , ft. 1&(, Ae usJ--_
-
❑Monitoring ❑Recovery ft. ft. 1
Injection Well: ft, ft. .
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACE(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑AquiferTcst ❑Stormwater Drainage ft. ft. ! • __
❑Experimental Technology ❑Subsidence Control ft. ft. 1
❑Geothennal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIP'r1ON'(color.tinniness,soil/rock type.grain size,etc.) _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) ft. Is. `G i C�
4.Date Well(s)Completed: S 2Z- $ Well IDn oZ II' 3U ft. J ,c'`
5a.Well Location: -30 R. d,((t_ft. thfGn f e '%E',_e _.,`R'tiftL
ft. rt. ,
•as?, Il,,,, +eft, S AUG 2 a'2023----1
Facility/Owner Name Facility iD!!(if applicable) Gq ft. ft. (,,
? .-- id . •tlI, cif - Z�v(>6� lfa.r:n c, 71514 R. ft. inr:r�v '�' '3 Li"
V
Physical Address,City,and Zip -__i
I 21.RF.MARICS I +.i
N�i�c Used hardened steel drive shoe. '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'I
(if well field,one ledlong is sufficient) 22.Certilicati •
y.L �Jd 1e(Al N 7 .7?.W Z w ,
S=zz-z3...
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor I, Date
fly signing this font./hereby certify that the well(s)was(were)constructed in accordmcc n ltn
7.is this a repair to an existing well: ❑Yes or eNo ISA NC,IC 02C.0100 or 15.4 NClC 02C.0200 Well Construction Standards and than a ci •,•
If this is a repair,fill out known well construction information and explain the nature oldie of this record has been provided to die wel!owue1%
repair under 1121 remarks section or on the back of this form.
,23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction init.
For Geoprobe/UPT or Closed-Loop Geothermal Wells having the same
construction,only I OW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (i s (ft.) ,
•For multiple wens list all depths if different(example-3©200'200'and 2 a 100') Submit this G�V-1 within 30 days of well completion per the following:
24a. For All Wells: Original form; to Division of Water Resources_(DWA),
10.Static water level below top of casing: Z. 0-0 information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
24b.For Injection Wells: Copy,to DWR,Underground Injection Control (WC:)
11.Borehole diameter: 6 (in.) Program, 1636 MSC,Raleigh,NC 27'699-1636
12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to tli
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departm entlof the county where installed • •
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCLI
7BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13u.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
Fonn GW-I North Carolina Dcparuncnt of Environmental Quality-Division of Water Resources Revised 6-6-20t::