GW1--05521_Well Construction - GW1_20230825

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: `-
1.Well Contractor Information:
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• Landon Phillips 14.WATER ZONES ,. ,•'11'.I -
Well Contractor Name FROM TO • DESCRIPTION
3441 A t alp ft. dss ft. a�i ;µ -
ft. ft. SDI
NC Well Contractor Certification Number
15.OUTER CASING'(for mul6,casedlwells)OR LINER(if ap licable)
NW Poole Well and Pump Company FROM_ ,TO DIAMETER I THICKNE
DIAMSS iMATERIAL
ft. •ft. I M.
Company Name
/, y 16.'INNER CASING OR TUBING(geothermal closed-loop) '
2.Well Construction Permit#: L71 _G lam-SO ^Z02 Z FROM TO DIAMETER ' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) _fit. ft. I in. -
3.Well Use(check well use): ft. ft. in. .
Water Supply Well: 17:SCREEN.. ., ''I .,. '
FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fit.._,. ft. in.
OGeothermal(Heating/Cooling Supply) erlftsidential Water Supply(single) ft. ft. in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT • .I
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: I ft - ft.
OMonitoring ❑Recovery ft. ft., •
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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. ft. •
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer .20.DRILLING LOG(attach additional'sheets if necessary),
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PRO, TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) J
:1 rt. �6 ft.
4.Date Well(s)Completed: He- 2 3 Well ID# . ft. ft. c� '
5a.Well Location: ft. ft. (.., f
"(kirk �?vi
t1 e N ft. ft k \L.�1 l ��
Facility/Owner Name Facility 1Dti(if applicable) ft. ft.
3 333 C t lit e e.m,:i1 0r 2 t II n C 115g7 ft. ft. • ' A U G 2 5 202
Physical Address,City,and Zip ft. ft. lfl1ti'FTsa't{:1 Pr,.4r ,m Ur
q,free. -21.REMARKS '.. .. ' .
Used hardened steel drive shoe. DWOJBOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J
(if well field,one lat/long is sufficient)
105. VI o75 N7 2MU?' 22.Certificati
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: es or 1No ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well constructio information and explain the nature of-the of this record has been provided to the well otvner.
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repair under 121 remarks section or on the back of this fond
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to,provide additional well construction infr•
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 necessary.
drilled:I 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q1oo') Submit this GW-1 within 30 days of well completion per the following:
w 24a. For All Wells: Original form to Division of Water Resources (DWR),
]0.Static water level below top of casing: (ft) Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" . I
11.Borehole diameter: •• 5 (in.) 24b.For Injection Wells: Copy to DWR,Underground'Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary I
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over,100,000 GPD:Copy to DWR,CCPCU 4
BLOW Penn it Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: •
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13b.Disinfection type: HTH Amount: 1 lb.
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018