GW1--05520_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Landon Phillips 1
14.WATER ZONES I •
•
Well Contractor Name FROM TO DESCRIPTION
I I
3441A rt. ft. 4
rt. a. -I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if op licable)
NW Poole Well and Pump Company FROM To DIAMETER I THICKNESS I MATERIAL
Company Name ft. ft. r- in.
16.INNER CASING OR TUBING(geothermal closed-loop) • •
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constntctlan permits(i.e.UiC,County,State,Variance,etc.) 4.5 ft. 5-00 ft. / i in. coo Al /d�`y --1
3.Well Use(check well use): ft. ft. in. -i
Water Supply Well: 17.SCREEN
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL -I
❑Agricultural - ❑Municipal/Public ft. ft. in., .
,Geothennal(I-ieating/Cooling Supply) l 1Residential Water Supply(single) ft. ft. in.:
� I
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT •
❑irrigation ❑Wells> 100,000 GPD - FROM TO MATERIAL EMPLACEMENT METHOD Si AMOUNT
Non-Water Supply Well: 0 ft. rep ft. 3e".4,4 If �� vier",
❑Monitoring ❑Recovery 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 ❑Stormwater Drainage ft. H.
❑Experimental Technology ❑Subsidence Control . \ft. ft. -=I
OGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hordness,soil/rock type,groin size,etc.)
❑Geothermal(I-Ieating/Cooling Return) ❑Other(ex lain under 1121 Remarks) 0 R. el R. T S
d� O
4.Date Well(s)Completed: 3 / .a 3 Well ID# ft. /d ft. 5146,
Nb t G its,
5a.yWell Locations: o /� ft. >COv ft. 6'gAN.I W`j
a iI SstA L am fib ierT S ILL lr- ft. ft. I ."�'„?;
p r -t ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ,..........0�..a
/a effr/oZ 1)5 fib C/MS> ft. ft. MR; 2 5'202
Physical Address.City,and Zip 12`'�6 0'7 ft. ft. 1
[ inkrilr-y'th ^0.a
it uroi
/ 4 21.REMARKS • Dl (�'�r^:/'. �"
County Parcel identification No.(PIN) Used hardened steel drive shoe. {
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient)
/� �/(� / -/� Q r t� 22.Ccrtiliicati
3`�. U -tQlfJJ3 N `-/ .lo 3_I 5O� _
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6.Is(are)the well(s):VPermanent or ❑Temporary Signature of Certified Well Contractor i Date
By signing this form,I hereby certify that the ive//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Vo iSA NCAC 02C.0100 or 11.1 NCAC 02C.0200 Well Construction Standards and that a co.:0
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 owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geopt obe/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 necesslii,.
drilled 3
•24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Soo ft
For multiple wells list all depths if different(example-3@200'and 2@100') ( ) Submit this GW-1 within 30 days of*ell completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DMZ.),
10.Static water level below top of-casing: (ft
If water level is above casing,use"i" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
y
Rotar y
12.Well construction method: • 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to ttt:,
(i.e.anger,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,CCPCLIA
13a.Yield(gpm) '-- Method 13- - Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: I IiI Amount: 1 lb'
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2(11 is