GW1-2023-00892_Well Construction - GW1_20230120

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For Inlcnitil Usc Only:
1.Writ Contmelor 1nfoTnallmi:
London Phillips 14,WATER 7.ON£S
FROM TO DF.SCnIr TIoN
Well Cont".0of Nama
3441 A /yo rL /9 r (I.
NC Wen Crndtadru Cenitication Number IS.OtrrER CASING for muh6cmrd welb OR LIVER f lleable
NW Poole Well and Pump Company rnum TO DIAAfETEn TInCXNrSS MATERIAL
Conµony Nnn a 16,INNER CASING Olt TUBING eolhorin I clmed-loo R -
OA1 To DIAarsrEll THICKNESS
2.Well Construction Permit 11, ) S� �� r ri. R. in MATrR1AL
11a nA nprl4rble mill rnnrm+raon permlu(tc.UIC,C 0"Store,Pmictim efe.)
fl. tt. Iti
3.NYcll Use(check well use):
17.SCREEN
Witter Supply Well: in011 f TO O. IrIM1LT In,
SLOTSry,F. Tit "MS MATEMAL
OAgriculluml ❑Municipal/Public b
OGcothermol(itcaling/coolingSupply) Jicsidential Water Supply(single) f. ft. la
Olndustrial/Commercini •. Okcsidcntial Water Supply(slarel) 18,GROVT
Olrvi ation OWells>100000 GPD FROM I TO n tPRIAI 9,MPIA F IFVTMYTIOD& M1
Non-Water Supply Well. © h. ft.
OMoniloring oRecovery ft. ft. trr
injection Well: R. R.
OAquifer Recharge OGroundwaler Remedialion
19.SANDlGRAVELPACK ara lieabie
DAquirer Storage and Recovery OSalinityBarrier FROM I TO I MATERIAL E IPLAMILN-rMEntOD
OAquifcrl'cst OStomnvaterDrain3ge [t. R.
❑GxperimentalTechnology ❑Subsidence Control
❑Geothermal(Closed Loop) 0'1'mccr 20.DRILLING LOG allach additional sheep If newsta
OGcothermal(Hcating/Cooling Return) 001:cr(explain under N21 Remarks) FROM To DESCRIPTION rotor,hnrdnef talUmk a ,,In 11r,,era
O R. It. (o 501
4.Dale Wcll(s)Completed: 20­31 Well iDN fl c�, jr�ft' C r� „r�` v WED
-a.Well Location: Ld H' m f I' '7 rGa A I e �
r I'sh iL 2Q23
rautitydO.�ncrNa1)nm I f Facility IDN(tfopplicable) ft. ft.
SO CaclL/lst �Ct/ ZeICA R, fb lnjorvi$liun Pr,:.zavx1q Urra
IM, ua1 Address.City,and Zip ft. A. ` r 13G
'7rG� 21.RENIARKS
County Parcel Identification No.(PIN)
5b.1-altitude and longitude in degrees/ntinutee/seconds or decimal degrees:
(ifwcll Geld,one latllongis sulueicnt) 22.CerlillcnI
35•�o�t�g3 N --IP.3��a W ��
`e-2o�Z-2
6.ls(arc)(lie well(s): 1>1Pennanent or CITcatpontry SignalurcofCcnjGedWcIIContractor Date
Bysigning tldr fait I hereby certijy�Aunt the irell(s)u•m(rvre)caainxted a,=ordafcc rcifl,
7.Is this a repair to an existing well: 0Ycs or 15Nu 15A NCAC 02C.0100 or IJA Ar IC 02C.0200 II ell Caminiction&ondanb aul dmi a copy
Ijrh s b a rcpn(,�1i our brain vcll caslnrcr(a,6 fornwllnn aul espinio the nofure ojfho njllils recoil Jim been prorided to the ire/l aware.
repair under R21 remnrki scc»on or an(lie back ojthir form. 23.Site diagram or additional well details:
8.For Gcoprohe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well construction info
Construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (ndd'See Over in Remarks Box).You may also attach additional pages if necessary,
drilled: i
24.SUBMITTAL 1NSTRUCTiONS
9.Total well depth below laird surface: d, (R') Submit(his GW-1 within 30 days of well eomplellon per the following:
/—mbilde cells list ail deptlu jdWereut(eran tic.3@200'end 20100")
241. For All Wells: Original form to Division of Water Resources (DWR).
10.Slatic water level below lop of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijunicr Icrc/if abUce ernlnA toe
11.Borehole diameter: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUQ
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well construction method: 24c.For WalerSu I and O en-Lou GeoWernml Return Wells:Copy to the
(i.e.
anger,rotary,cabtc,direct pas4 cm) county envuoltmental ea t t epanmcnt DI t to county where installed
FOR WATER SUPPLY WELLS ONLY: 24d,For Water Wells odueln over 100 000 GPD:Copy to DWR,CCPCUA
BLOW 1'cnmt Program,I IS',knlclgh,N 27 1 161
13a.Yield(gpnl) d Method of rest:
13b,Disinfection type: HTH Amount: 1 lb,
Funs G%v.1 Nor ill G,aotina Depa,talent of 8aviroanrutal Qunljny-Diviliun of Watar Resources Revised 64-2018