GW1--05748_Well Construction - GW1_20240926

WELL CONSTNUCT.WIN KltLUBU! (law-1) I I VI "P"P""' """' '•
_._ .
1.Well Contractor Information:
Landon Phillips 14.WATER ZONES • -j
FROM TO DESCRIPTION I
Well Contractor Name v ft. 255 ft. I m !
3441 A614e.
'1' • /
NC Well Contractor Ceni0cation Number 15.OUTER CASINGr mi lti s ells')OR LINER Lra lieable)
FROM TO DIAMETER THICKNESS MATERIAL -
NW Poole Well and Pump Company t I ft. I � ft. I 6 in- I - '4-r , 4,10"`'a e
Company Name N/4 16.INNER CASING OR TUBING(geothermal closed-loop) -�
FROM TO DIAMETER THICKNESS MATERIAL
2.Wc11.Construe6on Permit NI: fL ft. is _1
List all applicable well construction permits(i.e.WC.Cotmry,Slate.Variance.etc.)
ft. ft. in. I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _I
)(Agricultural ❑MuniciP al/Public ft. ft. in.
fit,
❑Geothermal(Heating/Cooling Supply) O esidential Water Supply(single) fL rL in. _.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Wells>100,000 GPD FROM TO KEIRlii.eAp. EMPLA/CEEMENT METHOD Si AMOUNT_
❑Irrigation fL �1� fsj,.i 1 Jv -Non-Water Supply Well: GO ✓'7 P'
❑Monitoring ❑Recovery ft.
-
ft.
Injection Well: ft. ft.
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL
EMPLACEMENT METHOD
❑Stormwa►er Drainage ft. ft.
❑Aquifer Test _t
❑Experimental Technology ❑Subsidence Control ft. ft. i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.sail/reek type.trig stu,etc.) t
❑Geolhermaf(Heating/Cooling Return)P / ❑Other(explain under/121 Remarks) p� ft e1 IL '--�p �jp�'
4.Date Well(s)Completed: eS la--23 Well ID11 tan ft. J 5 ft. c�/ , Y _ I
S f6 !J`ft. G�t'h1I f�
SOS I
Sa.Well Location: ft.
•
Plait fk)fir,e1 ft. . . _•
' 4 �l
rt. ft. \v..\..A 4.: Y i.�d.i
Facility/Ownery/ Name !1 Facility ID.H�/(\),(applicable) ' A
3 1 7 5,m$ �rd�AA� Iwr,+-d 1 rrRwtvll'f'A-1 f. SEP 2 O 2024 --1
Jft. ft.
Physical1.,dres,City,and Zip �� ZJ RJ
` 2l.REMARF:S Ir.`.�tR::.t ;: 'r t� `�
{Gnk.�en t
Used hardened steel drive sht� •'� �'� l
County Parcel Identification No.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/lon'is sufficient) 22.Certilleati
17t1t. I l N 1 . 7fit 41 61 w .51-140-Z
743
Signature of Certified Well Contractor - Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary
By signing this farm,I hereby certify that the well(s)was(were)constructed in acconlance wit.;
7.Is this a repair to an existing well: ❑Yes or LINO ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 IVeil Cmutntction Smndanls mid that is CO...."
If this is o repair• ill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under t21 remarks section or on the bock of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction int:
8
c.For Geo ,o only G -1 Closed-Loop Geothermal NUMBERs having the samells (add'Sec Over in Remarks Box).You may also attach additional pages if necessar,.
construction, I GW-1 is needed. Indicate TOTAL of wells
drilled:a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -3O r. (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths((different(example-3Q200•and 2©l00')
ZD ( ) 24a. For All Wells: Original form to Division of Water Resources (DW11.),
10.Static water level below top of easing: fL 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(MCI11.Borehole diameter 6 (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to ilk;
(.e2.Well construction ca tle, method: •
(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 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Z. Method of test:
13b.Disinfection type: HTH
1 lb.
Amount:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-7.e0 t::