GW1--05517_Well Construction - GW1_20230825

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I.Well Contractor Information:
Landon Phillips _._.
P 14,WATER ZONES • I ! I
Well Contractor Name FROM TO DESCRIPTION _i
3441 A f(,.5 ft. (76 R. 7_91°!'1 I
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased iwells)OR LINER(if ap picable)
NW Poole Well and Pump Company FROM TP DiA ETER I THICKNESS MATERIAL -
Company Name t( ft. 6Y ft- -6 I In. 'f l TC,(U!--ef -
/'—' / 4/p_ 16.INNER CASING/// OR TUDING(geothermal closed-loop) /
2.Well Construction Permit#: v V" - 67 I`I l 0 ��G FROM TO DIAMETER I THICKNESS MATERIAL __,
List all applicable well amyl-action permits(i.e.U/C,County,State. Variance.etc.) ft. ft. I in. _
3.Well Use(check well use): ft. ft. in. i
Water Supply Well: 17.SCREEN
FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑Municipal/Public ft. ft. in. i
❑Geothennal(Heating/Cooling Supply) ,Residential Water Supply(single) R. ft. in. .- .
❑bndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
❑irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT 5IEI'1tOD St AMOUNT
Non-Water Supply Well: - Q ft. l� ft. /- tiI,,piy (OOP(2
❑Monitoring ❑Recovery ft. ft. ( /
t
injection Well:
ft. • ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑SalinilyBarrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑StormwalerDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION colon hnrJncss,soil/rock type.grata size,etc.) i
OGeothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) (t a R. 50 ! 4.-4.Date Well(s)Completed: S_3 7-3 Well IDN a ft. b 3 ft. G/G-V
•
5a.Well Location: -6:3 ft. asst. ( it rf[ .s --. -;'���-- sl
•UP+OA -c,mpcgV ft. ft. I {� }
Facility/Owner Name Facility ID11(if applicable) ft. ft. AUG L 5 2023 - i
'7� �c1 3UG.1G.Pcf 11�1en /(Nc -75!( ft. II
it'�`Gr�ra?i1 taf Gh�tint
Physical Address,City,and Zip ft. It. Q{f�t�t+'3L�,� I
W�ICe 21.REMARIGS . —
1 l Used hardened steel drive shoe. {
Courtly Parcel identification Na.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -I
(if well fie d,one lat/long is sufficient) 22.Certi(➢cali .
35. 6'71Q5 N -Pb.17610 --1 W S _ '--z
G.Is(are)the well(s): ❑Permuncnt or ❑'Temporary Signature of Certified Well Contractor �� Dale
By signing this form,1 hereby certify that the well(.)inns(Were)constructer/in accordance u•1tn
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or 15,1 NCAC 02C.0200 IVel/Construction Standards a l that a co.•,•
If this Is a repair,fill out knmrn well construction Information and explain the nature of the glints record has been provided to the well owner.
repair under 1121 remarks section or on the bock of this form.
23.Site diagram or additional well details:
S.For Geoprobe/UPT or Closed-Loop Geothermal Wells having:the same You may use the back of this page to provide additional well construction int.
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You;may also attach additional pages if necessary.
drilled:t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (ft.)
•For uudtple wells list ail depths if different(example-3 a 200'and 2 ct l00') Submit this GW-1 within 30 days oflwcll completion per the following:
24tt. For All Wells: Original form'to Division of Water Resources (D\VP'u,
10.Static water level below top of casing: 01) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b. For injection Wells: Copy to DWR, Underground Injection Control (11K1
1 I.Borehole diameter: 6 (in.) Program, 1636 MSC,Raleigh,NC 27399-1636
12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to th.:
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed '
I .
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCI.IA.
BLOW Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7 Method of test: •
13b.Disinfection type: HTH Amount: 1 lb. .
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-20 I t: