GW1--05511_Well Construction - GW1_20230825

1 ;
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ;
1.Well Contractor Information: 1
Landon Phillips I I -�
14,WATER ZONES • 1 I '
Well Contractor Name _ FROM TO ,DESCRIPTION
3441A (o S ft. 7 o ft. /a
ft. ft. Up I
NC Well Contractor Certification Number
15.OUTER CASING(for'multi-cased wells)OR LINER(if ap licable)
NW Poole Well and Pump Company FROM TO DIAMETER I THICKNESS MATERIAL
Company Name ..1.- ft' L/ ) it 6 I in'l ,/i ''� (- 1J
✓
/• 16.INNER CASING OR TUBING(geothermal closed-loop) • •
2.Well Construction Permit il:( )1_J -(.) 5-S-1 (- ZGZ Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) ft. ft. •t in.
-I
3.Well Use(check well use): ft. ft. .in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER ,SLOT SIZE THICKNESS MATERIAL _
DAgricultural ❑Municipal/Public ft. ft. in.
- ❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) -�
ft. ft. in, ',
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT --•
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL: EMPLACEMENT hIETHOD&AMOUNT
Non-Water Supply Well: G ft. -O fL enn1 k, /,, -
❑Monitoring ❑Recovery ft. ft. --7-1Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation __'
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft. I
OGeothennal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) •• ❑Other(explain under d121 Remarks) FROM TO DESCRIPTION(color,hardness,saiurock type,grain size,etc.)
6 7 .
o�S�. _1
4.Date Well(s)Completed: 3 2a'o' Well ID?! ..Z ft. 3 G ft. c j't i I
�l. 1
5a.Well Location: ,3o ft. I U S- ft. C7r.1.4 r k r_I
,S i�n Gl ft. ft. "�^'
al 0 c0 n a r �
Facility/Owner Name Facility IDI(if applicable) ft. ft. � x...l�
6/61w ��f.di lest (2 .1(95 h, (1 ( 2-1 1 '0 ft. ft. AU Li 2 5'2023--,
Physical Address,City,an Zip ft. ft. _ 9�
21.
t Olt REMARKS (ftif rwa`L�V tr+v v� t
County L Parcel Identification No.(PIN) Used hardened steel drive shoe. -i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certilicati
2S. 1¢11+7Le N 1(6- .1i W •-22-z
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the,vell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It No !SA NCAC 02C.0100 or 15A NCAC 02C.0200 1VeIl Construction Standards and that a ca.:r
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 owns.
repair under 1121 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info,
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:+ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 S (ft) I
For multiple wells list all depths ifd�erent(example-3 tt 200'and 2Q100') Submit this GW-1 within 30 days of fell completion per the following:
10.Static water level below top of casing: Z 0 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If eater level Is above casing,use"+"
2,Borehole diameter: 6 (in.) 24b. For Injection Wells:Copy to DWR;Underground Injection Control (IUC t
Program,1636 MSC,Raleigh,NC 27699-1636
y
Rotar '
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to tli.
(i.e.auger,rotary,cable,direct push•etc.) county environmental health departmentiof the county where installed
I.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over;100,000 GPD: Copy to DWR,CCPCOA
13a.Yield(gpm) / Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised G-G-201 t: