GW1--05518_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD GW-1
) For Internal Use Only: 1 - '
1.Well Contractor Information:
Landon Phillips i
14.WATER ZONES . I I ,
Well Contractor Name FROM TO DESCRIPTION
3441A Zo ft. ?S ft. !O 1
aaf ft. . ft. a O I ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased'wells)OR LINER(if np licable)
NW Poole Well and Pump Company FROM TO DIAMETER I THICKNESS MATERIAL -
Company Name it• g'•3 ft. 'I in. r ?/ 2 rV
16.INNER CASING OR TUBING(geothermal closed-loop) t,•7L.` " _
2.Well Construction Permit#:C 4AI 09'.7S52 `2023 FROM TO DIAMETER : THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 'i in. `l
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. . ft. in.
OGeothennal(I-ieating/Cooling Supply) ('Residential Water Supply(single) -
ft, ft. in. `
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. 2.o ft. �iIt+fitltk ce'c'
❑Monitoring ORecovery ft. ft. `"
Injection Well:
• ft. ft. -
❑Aquifer Recharge ❑Groundwater Remediation .......
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft. 1
1
❑Experimental Technology ❑Subsidence Control ft. ft. i
OGeothennal(Closed Loop) ❑Tracer . 20.DRILLING LOG(attach additioniil sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRITT[ON(color,hardness,satUrocktype,groin size,etc.)
V ft. a ft. Tr�I i
4.Date Well(s)Completed:a.,..ay a3 Well ID a# - ft. LeO ft. -�
5a.Well Location: it y ft. ��r' �
Homes ft. f. i, :.. L.i Li
Facility/Owner Name Facility 1D#(if applicable) ft. ft. i , AUG z2g23 -I
t des edy ft lafs 1 % rn e_ ft. ft. i Fi �i
Physical Address'.City,and Zip ft. ft. Infor4r•,'Nicn nitre ey tilt
Ca/t q":C-
f^ Ve.� 21.REMARKS
County Parcel Identification Na.(PIN) Used hardened steel drive shoe. 1
J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) nn 22.Certificati
.))5
z
)5.8(i0 `r��f N --7 •CP 3g57:-) W
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date �O�Z s
By signing this form,I hereby'cartify that the walks)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No /5A NCAC 02C.0100 or iSA NCAC 02C.0200 11'c11 Construction Standards and that a n::si
If this is a repair,fill out know a well construction information and explain the nature of the of this record has been provided to the well owner
repair under 1121 remarks section or on the back of this form. i
23.Site diagram or additional well details:
8.For Geopr•obe/DPT or Closed-Loop.Geothermal Wells having the same You may use the back of this page to provide additional well construction ink,
construction,only I 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 1.
L/
9.Total well depth below land surface: d S ft
For multiple wells list all depths ijr/fferein(exam pie-3@200'and 2©100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2 O fL 24a. For All Wells: Original form to Division of Water Resources (DWR),
',
(
If water level Is above casing,use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
II.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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 th.,
(i.e,auger,rotary,cable,direct push,etc.) county environmental health departmentiof;the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing.over110'0,000 GPD:Copy to DWR,CCPCII_'.
13a.Yield(gpm) 30 Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
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Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-201 r