GW1--05758_Well Construction - GW1_20240926

WELL CONSTRUC•r1Vly K1L(JtWL (x NI'-II I1 ut ....,....�. V.I. - _
I.Well Contractor Information: -
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Landon Phillips .14.WATER ZONES •
FROM TO DESCRIPTION
Well Contractor Name I f.s ft. 1 0 ft. 1 9�/h _
3441A olg 3 rt. Q Oft. 'L.8t.90,'
NC Well Contractor Certification Number 15.OUTER CASING(for multi used wells)OR LINER(if ap likable)
NW Poole Well and Pump Company FR FROM
it. I TO ft.
D( R in I THICKNESS
MATERIAL f
Company Name A/ / 16.INNER CAST G OR TUBING(geodrermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N: fL fL in. i
List all applicable well construction permits(i.e.U1C.Coutrry,Slate.Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in. _
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO IOTERIAL Oft. Ct D rit. (//1r r'J� EMP �E)Plif,METHOD d.AMOUNT
- �
Non-Water Supply Well: -
❑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 _
❑Stormwater Drainage ft. ft.
❑Aquifer Test g -'
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.( _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) 0 ft. 113 it. /2 Se I►C
4.Date Well(s)Completed: S-I(-Z3 WellIDN a ft. 7ri,` ft. CI(.-y •-
r` i0 ft. jr‘est-t•-�
5a.Well Location:, _
1U H &(on ft. fL i
s
Fa lilyIDS(ifapplicable) ft. ft. ..`-'-k. s'! 17 1
Facility/Owner Namy
f/''�S f, ft. ft. `;F P 2 t:
_3q 41�
a �� T � 'Wk. t024.
Physics! dress.City,t Zip p2 7�+Zs i t, ..i r ;••r .ni.'_. 1..44
21.REMARKS
Unk�f Used hardened steel drive shoe. Lam`'`"f�"`'
t
County Parcel Identification No.(PIN) ;
1
5b.Latitude and longitude in degrees/minutes/secbnds or decimal degrees:
Orwell field,one IaVlong is sufficient) 22.Certificati
3c,. 1 1i3►1 N 7i.9/$1+761 w _, 51 i z3,.
Signature of Certified Well Contractor . Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary
By signing thisform,I hereby cent(that the we/l(s)was(were)constructed in accordance wit.:;
7.Is this a repair to an existing well: ❑Yes or to ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 IVell Construction Standards and that a 4:6...r
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 scoter.
repair under M2l remarks section or on the back of this form. 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 ira.,
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sec Over in Remarks Box).You may also attach additional pages if necesse+!.
drilled:t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �c (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-38200'and 2®100')
(ft) 24a. For All Wells: Original form to Division of Water Resources (D\\nil.;:
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If writer level is above casing,use"+"
24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUD
11.Borehole diameter: 6 (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method:
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to lilt
(i.e.auger•rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.F rP Water Wells ogram,161 l MSC,Raleigh,N 100,000 CPU:Copy to DWR,CCPCU-..
13a.Yield(gpm) S Method of test: BLOW
1
13b.Disinfection type: HTH
1 lb.
Amount:
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-"G3 i