GW1--02410_Well Construction - GW1_20240422

WELL CON S'1'1{UC 11uty KL+LUIW AJ VI!-1
1.Well Contractor Information: ,
14.WATER ZONES
Landon Phillips FROM TO DESCRIPTION —
Well Contractor Name
v ft. ^ S ft. 2 "
3441A rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-case)wells OR I LINER if a l�MhTITe L
FROM
(1 TO DIAMETER
ft. fr. 6 in. ( ER1A1
NW Poole Well and Pump Company -•
16 INNER CASING OR TUBING(gcoNtermal closed-100 .1Company Name 9a O FROM
D1.\METER 'Tt11CKNESS MATERIAL ___
ft. ft. ir_ 1
2.Well.Construction Permit#: -- --
List all applicable well construction permits(i.e.VIC,County,State. Variance,etc.) ft. __t. in
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER c1LOT SIZE THICKNESS MATERIAL.
Water Supply Well: ft. in.
❑Agricultural ❑Municipal/Public ft.
❑Geolhennal(Heath) Cooling Supply) "(Residential Water Supply(single) ft. R.
In. '
❑industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM TO MATERIAL EMPLACEMENT 111E110D&AMOUNT_
❑ n-\Vaon ❑Wells> IOO,000GPD O tt. ft. (_I/���j� _
R. ft.
Nonter Supply Well: '
❑Monitoring ❑Recovery
Injection Well:
ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if anplicnbleL EM1tPLACEntENr niET 1(OD
TO
❑Aquifcr Storage and Recovery OSalinity Barrier FRO11I M1h\TERIAL—
R
°Aquifer Test ❑ rt.Stormwater Drainage 1
i
°Experimental Technology ft. ft.❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothennal(Closed Loop) ❑Tracer PROM 1.O DESCRIPTION(color,hardness,soil/rock type,grain size,cic.l _i
❑Geothermal(Heating/Cooling Return)
❑Other ex lain under tt21 Remarks) 62 ft. ft. 7-61,5*-0,
4.Date Well(s)Completed: . 171.33_ Well ID11 ot2
4
� ) it. f0 S rt. 9r�i./►i.G� I
ia.Well Location: �/� ft. ft. (J �r�• • - �'�!t. �_,
(,rl'u -�L�(u/'rKllks ft. ft. — PR Q�
Facility/Owner Name Facility IDH(if applicable)
1 • N �7 ft. ft. I
53'7 �ty 1 r�0(� Pb��dn c a ♦sy ft.
Physical Address,City,and Zip 21.REMARKS 1
Sohn fD S0 Used hardened steel drive shoe.
Parcel Identification No.(PIN) i
County —'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certificali
(if well field,one lat/long is sufficient) � /
35 ,-�ON ^ � ,�� � _ 1G-4=23
4reoettwcoiitor .
Date
6.ls(nre)the well(s): crmnnent or ❑Temporary
By signing this farm.i hereby certify allot the well(s)tins(were)constructed in accordanc_wit:.
7.Is this a repair to an existing well: ❑Yes or or‹; !SA NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and dun a co
of this record has been provided to are uep owner.If this is a repair,fill nut known well cathsinictioa information and exploit:the nature of the
repair under 1121 remarks section or on the hack of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction uii..
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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 necessa
24.SUBMITTAL INSTRUCTIONS
drilled:t
9.Total well depth below land surface: SOS- —(ft) Submit this GW-i within 30 days of well completion per the following:
For multiple wells list on depths if different(example-3 a 200'and 2®1001 _
�, . 24a. Far All Wells: Original form to Division of Water Resources (D\k'fi.):
10.Static water level below top of casing: ���,� _— (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"� 24b. For Inclio
icn Wells: Copy to DWR, Underground injection Control QUt:
11.Borehole diameter: 6
(in.) Program, 1636 MSC,Raleigh,NC 27699-1636
Rotary 24c.For Water Su 1 and O en-Loo Geothermal Return Wells:Copy to di::
1.e2. auger,g construction ca le, method: county environmental health department of the county where installed
•
(i.e. rotary.cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: 24d.For Permit PrWater Weels 161 MSC, 27699-M: Copy to DWR,CCPCIir.
13a.Yield(gpm) Method of test:
BLOW
13b.Disinfection type: I-IT 1611
1 lb.
Amount
Revised 6-6-30H
Fonn GW-I
North Carolina Department of Environmental Quality-Division of Water Resources