GW1-2023-00889_Well Construction - GW1_20230120

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WELL_CONSTRUCTION RECORD(GW-1) For Internal(Ise Only:
1.Well Contractor Information:
Landon Phillips 14,WATER ZONES 1
Werl Contrxtor Nsmc ntobi TO DFSCRIMON
�S-rc. t,
3441A 10
rr.
NC Well Cmutanor Certification Number
r h (KO ft.
�15.OUTERCASING rarmultitssedwelly OR LINER Ares GoablcNW Poole Well and PUmp Company oM TD DIAb1CTIM TIUCKMFSS TIATERIAL( tL �3 rr. Cy to d 1
Company Namc �O S
3/6o/^ I0.INNER CASING OR TUBING mthermnl elosed400
2.Well Construction Permit 11. � FROM TO DIAMETER TIIICiGNM SIATFRIAl.
Its'all applicable urll trlastntetton perauts(l,e.UIC,Cotm0,,S ae,Yorlatce,etc.) ft. 't. In.
3.Well Use(check well use): ft. B. In.
Water Supply\\'ell: IT:SCREEN.
DA iculluml FROM TO DIAM FTFR SLOTSrl6 MC&YESS MATERIAL
❑MunicipaVPublic O ft. 3s5-fl. n
❑Geothermal(Hclting/Cooling Supply) sidenlial PPY(single)
Water Su IOar
ft. in.
rL
❑Industrial/Commercial []Residential Water Supply(shared)
Is.GROUT"
IDIrrigation ❑Wells>IQOOOO GPD FROM TO aIATEnIAL EMPLICEbIF17T b1EIItOD&AafOUNI
Non-WatcrSupply Well: (] fl• ft. fiArFG /-
OMoniloring ORecovery ft. B,
Injection Well:
OA uifcr Rcchnr c ft. It.
q 8 ❑GroundwalcrRcmcdintion
❑AquifcrStorngeandRecovery ❑Salini Barrier 19.SANDI RAVEL PACK ifn lteable
ty FROM TO MATERIAL EMPLICEMILM aIEIIOD
OAquifcrTest OSlormwatcrDrainagc O n. —2101- ft. �( 3
❑[:xperimcntal Technology OSubsidencc Control B, rl,
[]Geothermal(Closed Loop) []Tracer 20.DRILLING LOG frittacla old iNonotsheeu tfnecasn
❑Geothermal(fleating/Cooling Return)--- []Other(explain under Remarks) PnoM TO DFSLRIm'CION color ERG w Vnc61 e. ,tn srr.nr
(j B. I ') rt.
t a
4.Dnlc\Pett(s)Completed: LZ Well!Uq B. (p fa r # p.�
6a.Well Locution: (o R I,✓r
. .kf n. f,n ,�,e
"
Nl fi. ft. JAN
Faaccility/OwncrNaia; Fae O ilitylDn(irapplimble) ft. ft.
7 C!rn1 ��J 01- leo l 1C ft. ft. 6ri3IDD rtM3u ORS
Physiesl Address,City,an Zip n. R,
/ u
6-nn 1 K,.�tlt 21.REMARKS
County Parcel Identification No.(PIN) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.Due hulong is sufficient) —y Q" 2 22.Certificod p:
3'5' Q34gP-N V 10. J�� W
16-2 if— �
6.Is(nrc)the well(s): []Permanent or []Temporary Signaiury ofCcnificd Well Conuncmr Date
0ysignbig this jornt,]hereby eergry thal tho.imll(s)eras(wtro)mrulnicled ht aecon/arm•,wh
7.Is thiso repair to an existing well: ❑Ycs or ONo 1JANCiIC01C.0100orlJdNCAC01C.010011'ellCotwntetioaStandanbardtlwtotwp-
if this Is a repair•f ll out known ire//eonitr cilon h fonnntlon and erplalu the aawre of ha of llds record bar been provided to ibe mil ourrer.
repair wader a21 rentorkr see0on or on the back of thisjorat.
23.Site diagram or additional well details:
8.For Geoprobe/Dlrl'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional%yell construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft.) Submit this C1V-1 within 30 days ofwell
For nndrtple irr147/tit all depths fdtf(ereat(esaotple•3 00'atd 2a@100') Y completion per the following:
a() ) 24n, For All Wells: Original fo rn to Division of Water Resources(DIVR),
/f
f it titer ln•ri is abaft miln/;use"i Slade%rater level below lop of casing: (fL In(brmation Processing Unit.1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 pn•) 24h.For Injection Wells;Copy to DWR,Underground Injcclion Control(IUC)
program.1636 MSC,Raleigh,NC 27699-1636
12.Wcl1 construction method: Rotary
24c.For\Viler Su sl and O en-Lua I Geothermal Return Well%!Copy to the
Ox.auger,,utary,cebl°,dir<cr posh,tie.) county environmental hca th department of the county where msladed
FOR WATER SUPPLY WI:I,I,S ONLY: 24d,Fnr Water Wells producing over 100 0110 GPD:Copy to D%%T,,CCl'CUA
©LOW PcnnIt Progmnl,I I I MSC,Rulcigh,NC 27699.1611
� 13u.Yield(gpni) hlclbod of test:,
13b,Dislnfcction type: HTH Amount: 1 Ib•
t°"'i 41Y'1 North Carolina Deponmenl of Euvitmm"ental Quality-Divisiou orWatcr Resources Ravised 6.6.201 a
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