GW1-2023-00910_Well Construction - GW1_20230120

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\11LLL CONSI'ltUC11014 REC For M.-lnl Usa Only:
1.\Yell Conirnclor Infornmtlon!
Landon Phillips 14,1VNrJK ZONES
FROM TO Drscru 1071
WinCmdmetor NMI, f4 s' ft.
3441 A ft. n.
------------
NC Nell Comnxlia Cenificallon Nutnlier 15.OUTER CASING for mu111•emed wti�OR
Rifn lieabte
NW Poole Well and Pump Company FROM TO DIAIIGTEttrss AIAMIAL
� rr.
Cmnlnny Nonni I 16.INNER CASING OR TIDING eolhermnl elmed-lvo
FROM TO DJAAILTGR TItICIfNESs AfATG1rUL
1.\Yell Ca nslrucllon Permh H: h. fl. In.
l.ltt nl!ni;aJlMhle nrtl tominK'tlfNr pernad p.t.U1C.Cmony,Slate,i Arionce,etc.)
3.Well Use(check well use): 17.SCIU7P,N
wrilerSuppiy Well: FDoal To DUNF,TER St.O 517.E T1r1CIMICSs I AIATMI 1,
OAgricultunl fitt.,
unicipal/Public O D. 6SR. in.
OGcotherrml(I lcaling/Cooling Supply) sidcnliolWaterSupply(single) to0loditstrial/Commcrcial idcntial Water Supply(shovel) 18.GROtrr
Olrri ration OWclls>I00,000GPD Most TO at ERt I Ar u tir o-6 Anr
NoD-\\'atcrSupphyWell: O ft. a it. a.t-k pear
Ohtoiloring ORccavery ft. ft.
Injection Well: ft. ft.
OAquiferRediarge ❑GroundwalcrRemedialion 19.SANDIGRAVEL PACK ird livable
OAquifer Storage and Recovery OSallnityBarrier Fnonr I To I MATERIAL >"+rrucctitFxratentoD
OAquifer•fcst OStomlwaterDrainage A. fr.
❑GeperimcidalTechnology OSubsideneeControl ft. If.
❑Gcolitcnnal(Closed Loop) O'I'mcer 20.DIULLINGLOG intlachoddlfloanlshceuirnecceui
❑Geothermal(Heatin Cooling Return) ❑Othercelain under 821 Remarks Faoat To DE50tlrnon ramr oa dmt mmrock a purr em
D rr. a rr• TO so.\
4.Dale\Vell(s)Completed:&-z C'ZZ Well IDH
D. SrL C7ra�.
Sa.Wall Locnt(on:L r , i m }
5�Rr)rSYt f �`IOryt�S R. R. L., t o •D
pacirir)dO+vnaNmne Faeility11DO(ifopplicable) ff. R. '
�� �arclC�In1 VO,/ Z 10✓1 ft. R.
Phyaicaal Address•City,and Zip
�rG!\ fIG 1 �. r,
. 21.RFTIARKS """ ,•^ +•••+ UI1C
I 7'
County Parcel Idcntificmion No.(PIN)
5h,Latitude and longitude in degrecsJminules/seeonds or decimRl degrees:
(irrvell fiew,one bylong is sufficient) Z2.CCr1lBarl
gS.Qo5g0R N --)R. 30-7-?Qk W
6.Js(are)kite sveil(s): MPerutnneiil or ElTcnrpornry SignalureofCcalfictl Well Contractor ` Date
Uyrigrdn8 thtr�anr,J IrcrcGy errs jvhnt tfx trc//(.Q+vas(rare)rorutrueted In occordarn with
7,Is Ills a repair loan existing well: OYes or "UNu 15.4 NCAC 02C.0100 or ISA NGIC 02C.0200 D'e11 Cwmnicrion Slmuku,ls mui dmt a cam.
1fthir b o repaiq fill out himirri yell comm,eilar h Jnroraaen end explain the nature 01111e njdds record hdt been provided to the well tinter.
repair wider 421 remarks section or on the back ojtldr fomr.
23.Site diagram or addilimml well details:
8.For Gcoprobc/D11T or Ciased•Loop Geothermal Welts having Ole same You may use ilia back of this page to provide additional well construction info
Conswctiol,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovice in Remarks Box).You may also altach additional pages if necessary.
drillcd: 1 24.SUB6111TAL INSTRUCTIONS
9.7•utal well depth below land surrnce: C) (R) Submit this GW-1 within 30 days orwell Conlplcllan per the rollowing:
porendtlple wells Ibr all depda%doereia(example-301 00'and 2Q100')
24% For All Wells: Original form to Division of Water Resources(DWR),
IU.Slulic hater level below lop ofe.Tsing: (fl') lararmmion Processing Unit,1617 NISC,Raleigh.NC 27699.1617
1/unlcrk.-c1 it abort urrtng,me"+•"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
IL Borehole diameter: 62 (111•) program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.\Veil construction method: 24c.For 1Vnler Su Iv and O en•Loo Geolhernlal Return Wells:Copy to the
(i.e.
tn,0a,ranry,cable,direct purl\tie•) county environmental w l epanment o ilia county where� e�
11011.\VA•1•F.R SUPPLY WIU,LS ONLY: 24d.For Wafer WCIIs ro?gcIn over IUO 00U CPU:Copy to DWP CCPCUA
BROW Ycnnn Program. I I C,Rn mg r,N .1611
131.Yield(gpnQ, Method or test:
131).Disinfection type: HTH Amount: 1 lb.
puwn G1'J•I Nmth Cwolinu Dcparhrwnt orRavilornrwnlul Quality•DMilmr of Wator Ilrsourcca Roviscd 4.6.20IB
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