GW1--05512_Well Construction - GW1_20230825

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1.Well Contractor Information: •
Landon Phillips 14,WATER ZONES I 1 •
Well Contractor Name FROM TO DESCRIPTION _,+
&Lk ft. c2Lis' ft. / 1l __
3441 A 6i 5 ft. 20 ft. 7 A2
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
NW Poole Well and Pump Company FROM TO DIAMETER I THICKNESS MATERIAL _
„j_,i ft. Si
ft. 6 I in I CJ r J '1�G (}'�C C
f
Company Name 9 16.INNER CASING OR TUBING(gcolbermal closed-loop) • •
2.Well.Construction Permit H: /J_W- 016( 4 -20,2} FROM TO DIAMETER ' THICKNESS MATERIAL --
List all applicable well construction permits(i.e.UK:,County.Slate.Variance,etc.) ft. ft. im __I
ft. rt. ' in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAf11ECER SLOT SIZE C!I[CICNESS MATERIAL _I
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothennal(1-leating/Cooling Supply) Atcsidential Water Supply(single) ftL 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: /� It. 1 ft. .) J ap J IJ�)(1 __-_
❑Monitoring ORecovery C ft. �F� ft. ,I I
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remcdiation 10.SAND/GRAVEL PACK(if applicable)
❑Aquiter Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD ft. _.I
❑AquiterTest ❑StormwaterDrainage ft. +
❑Experimental Technology ❑Subsidence Control ft. rt.
OGeothennal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 'ro - DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) __
❑Geothermal(Healing/Cooling Return) ❑Other(explain under 1121 Remarks) 0 rt h j 1 ?'v/� �
y l
4.Date Well(s)Completed: -/-0(i1- Well ID// ot ft. 5'Li ft. c /t....-/ .I
rt. ft. C r�i`rI i f�-
5a,Well Location:v`/ -5e-� 70 S j q.. 0
• fy/ i SA 1 ft. ft.L ILC/ � aC.+E +.f E ;
Facility/Owner Name Facility IDU(ifepplieable)
/bos" le jcLLy Izi`di.e. Li,In e- wtNkL.- -05. yL ft. rt. AUG 2 5' 2023-..
ft. ft. i
Physical Address,City,and Zip a 7 S y t
Iitc4temou.... �C ?eSpr�t•t
�iC 21.REMARKS i EX; 1:,�: _I
�r 1.��'
'Used hardened steel drive shoe.
County Parcel Identification No.(PIN) -'1
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Certit-tcati , •
12Le.: I)Z•122I N -7b. a"i01‘21 W _ `J-zr-a3
❑'I emporary Signature of Certified Well Contractor ` Dote
6.Is(are)the well(s): OPermanent or
By signing this Jane,I hereby certify that the well(%)tins(tiers.)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or inNo ISA NC/IC 02C.0100 or 15A NCAC 02C.0200 IVell Construction Standards and that n cc;•r
If this is a repair,fill out known well construction Information and explain the nature of the of ids record huos been provided to the well owner.
repair under 1121 remarks section or on the back of ihls form. 23.Site ding"ram or additional well details:
8.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only'l OW-I is needed. Indicate TOTAL NUMBER of'wells (add'See Over'in Remarks Box).You'may also attach additional pages if necessary.
drilled:I 24.SUBMITTAL INSTRUCTIONS
9,'fotal well depth below land surface: 70.5 (ft.) Submit this GW-I within 30 days of well completion per the following:
'For multiple wells list all depths If different(example-3@200'and?a 100')
,,`` 24a. For All Wells: Original form' to Division of Water Resources (DW11.),
10.Static water level below top of casing: �(.y 01) 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 (lUs:)
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 thz
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departme(ntiof the county where installed '
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over'100,000 GPD:Copy to DWR,CCPCW..
BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) g Method of test:
13b.Disinfection type: HTf I Amount: 1 lb.
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Font GW.I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 t r