GW1--05513_Well Construction - GW1_20230825

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1.Well Contractor Information:
Landon Phillips 14.WATER ZONES • I' I n
Well Contractor Name FROM TO DESCRIPTION ----1
3441A 50ft. S90 ft• a(yQ/'1 f
b�fSIt. bc50 ft. S p� ..1NC Well Contractor Certification Number 15.OUTER CASING(for multi-case wells)OR LINER(if ap rlicuble)
NW Poole Well and Pump Company FROM TO DIAMETER I THICKNESS MATERIA -
-I-I ft. ‘.r! ft, 6 f in, .i 0 6 _ j0,0i-Gc) -.
Company Name /r'- 1 �r�/ 7 I6.INNER CASING OR TUDING(geothermal closed-loop)
2.Well.Construction Permit lf: v w-��`^/I _ v��� FROM TO DIAMETER I THICKNESS MATERIAL __
list all applicable well construction permits(I.e.UIC,County,State, Variance,etc.) ft. ft. in -
3.Well Use(check well use): ft ft to -•
Water Supply Well: 17.SCREEN
PP Y FROM TO nIAMSrsle SLOT SIZE THICKNESS MATERIAL -I
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothennal(I-leating/Cooling Supply) )(Residential Water Supply(single) rt. ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) lA.GROUT
❑irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: d ft. l30
ft. �„-y'_0/1 POv2 ---
❑Monitoring ❑Recovery ft. ft. /�
Injection Well: •R. ft. ----•
❑Aquifer Recharge ❑Groundwater Remcdiation 19,SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM , To MATERIAL EMPLACEMENT METHOD _-I
❑Aquifer Test ❑StonnwaterDrainage ft. ft. I • V_I
❑Experimental Technology ❑Subsidence Control ft. ft• 1 Ili
❑Geothennal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(colon hardness.soil/rock type,grain size,etc.)
❑Geothermal(bleating/Cooling Return) ❑Other(explain under 1121 Remarks) Cx.ft 1 ft. r;�,Q�1
4.Date Well(s)Completed:S-1-Z3 Well IDN ft. `.f. ft. tL '1 UL'`,/ •-�
rL� I
5a.Well Location:onC •�t'.1 ft. 7�.3 ft. (�,t�0A t ��„��"- t.14
. l
t o U�L ft. ft. V 1 t 'C L1 C Z V �4}• .J
Facility/Owner Name Y Facility ID!!(ifapplicable) ft. ft. AUG `�`� _..I
1466 Legk,�->" ic/Gij.t (--ca -C, Wait,. '
4 fes .VC- ft. ft. l 9 t
Physical Address,City,and Zip a 76t7 ft. fL !. Inftriviaticn Prnizae404 1,+r4ki
wck 21.REMARKS B)r�v1�vtid--i
t
Used hardened steel drive shoe. 1
County Parcel Identification No.(PIN) -
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --'
Orwell Geld,one Iat/loug is sufficient) 22.Certificati
(p• OLQ14- 4 N -fit• 56190511 W
6.ls(ttre)the well(s): ❑Permanent or OTemporary
Signature of Certified Well Contractor ; '�' Dale
By signing this form,i hereby certify that the sre//('9 was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L1No ISA NC,C 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a ca.-•r
!f this is a repair,fill out known well constnoction information and explain the stature of the of this record has beet:provided to the welllawner.
repair under 021 remarks section or on the back of this form. 23.Site diagram 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 inch
Odd'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
9.Total well depth below land surface: 70S (ft.) Submit this GW-1 within 30 days of well completion per the following:
'For multiple wells list all depths if diUerent(example-3 a 200'and?C3n 100')
24a. For All Wells: Original form to Division of Water Resources (Dwi'),
10.Static water level below top of casing: 7-0 24a.
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1,
24b.For Infection Wells: Copy to DWR, Underground Injection Control(IU'_I
11,Borehole diameter: 6 (in•) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24c.For Water Supply and Open-Lino,Geothermal Return Wells:Copy to tliz
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department'of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUW..
BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1 lb.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-ei11t:
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