GW1--05507_Well Construction - GW1_20230825

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I.Well Contractor Information:
Landon Phillips .14.WATER ZONES • 1 ; • ' ' • _i
TO DESCRIPTION 1
Well Contractor Name "��FROM R 7�r ft Z
3441A Ala n• ie( 5— fL c j `
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(Wart,Dcnblc)
NW Poole Well and Pump Company FROM TO DIAMETER I THICKNESS MATERIAL
t I ft. G 3 ft. G t )i—c G-1 \ijes ►t'?ej_.
Company Name
�/�/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Wcll.Construction Permit#: (.2 —( I/ 3( CnC(" Z 02 Z FROM TO DIAMETER I I THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. inn. --
ft. It. 'in.
3.Well Use(check well use): -li
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SI.OTSIZE THICKNESS MATERIAL _I
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geotitennal(I leatittg/Cooling Supply) pitesidential Water Supply(single) ft: ft in. ' _
❑Industrial/Commercial 0 Residential Water Supply(shared) •
IS.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD St AMOUNT_
Non-Water Supply Well: 0 fL Z 0 ft. izer.-6n4. r(�e-- -Y--
❑tvlonitoring ❑Recovery ft. ft.
Injection Well: ft. ft. I
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM 'ro MATERIAL EMPLACEMENT METHOD —,.I
❑Aquifer Test ❑Stonnwater Drainage ft. ft. '
❑Experimental Technology ❑Subsidence Control ft. ft. i
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,looniness,soil/rock type,groin size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under t121 Remarks) G ft. ,Z ft ice s�`
S
4.Date Well(s)Completed: —Z.S 23 Well IDN .Z ft. sQ ft. nCf ., I
5-(� ft. J ft. �ca t,e YL k_ E Z,'Id E.2
5a.Well Location: n ,
731/ 36 ft_ ;
rn on s rLrC'I r�r1
S ft. ft. AU6 2 5 2023
Facility/Owner •Name Facility IDII(if
5Co q 1(-w n l c, .s qv- -c)6 ry Ta rt f\cL,1/516 ft. ft. s II ��i^r r'r.: tinPhysical Address,City,and Zip (� ft. ft. j• DWC,` t
21.REMARKS I
C-. V o Used hardened steel drive shoe. i
County Parcel Identification No.(PIN) —..
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lilt/long is sufficient) 22.Certilcati
`. 5. cietti5 N 7b.7%10 W s-2-3-2-3.....
Signature of Certified Well Contractor •i `' Date
6.Is(are)the well(s): ❑Permanent or OTemporary '
By signing this f,rm,I hereby certify that then wehfs)was(were)constructed in accordance t,It4
7.Is this a repair to an existing well: ❑Yes or ONo iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a co......
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 u•el!intact.
I
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 info
S.For GeoprobdUPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells .(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:t f
/ s (ft.) 24.SU13htITTAL INSTRUCTIONS
i
9.'fotal well depth below land surface: /l rJ Submit this GW-I within 30 days of well completion per the following:
•For multiple wells list oil depths if different(example-3 a 200'and?a 100')
24tt. For All Wells: Original form;to Division of Water Resources (DWII.),
10.Static water level below top of casing: O (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water tote!is above casing,use"+" i
24b. For Injection Wells: Copy to DWR, Underground injection Control(1U,:)
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 tha
(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,CCPCU4.
77 BLOW Permit Program, 1611 MSC,Raleigh,,NC 27699-1611
tau.Yield(gpm) Z. � Method of test: i � '
lib
13b.Disinfection type: HTH Amount: i .
.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-:0tt: