GW1-2023-00893_Well Construction - GW1_20230120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Infornmlian:
Landon Phillips
14.IVAT1:R ZONF
NCI!Cown'tor Mama FROM I To DFSCIMPTION
3441A
NC Well COnundOrCenlfieallon Number
i'� R l`!l� e• 3 p�
I&OtrrF.tt CASING for muhn-ented vreils OR LINER a DI at,e
NW Poole Well and Pump Company room TD DIAa1P.rr.R TnICRNFSs MATERIAL
.h n. n. / ta.
Congnuy Nano 1 r b c)i5 CL
d LJ/�O 16,INNER CASING Oft TUBING cothentud dwell-loa
2.Well Construction Permit In rnOMf To Drnsrerr. ,Ir Y.NEss MTATERIAL
l.ht nl1 nl>,dlnuhle snlh rouunnmtton pernda(J.r.WC,Cnrnhry.Sforq 1'aNancc, I fI ff. In.
3.Well Use(cluck ncll use): ff. fr. is
FOAgricullural
Supply"Pell: 17.SCREEN
FROM TO UmAIFTER SLOT IT.E THICKNr_SS MATERIAL
❑MunicipaVPublichcmlal(11Caling/CoofingSupply) ViWidential Water Supply(single) D R In
OlndnslriaVCmnmcrcial ❑Rcsidcatial Water Supply(shared) i&CROUP -
OIITi afio'1 ❑1VCIIS>IOQ000 GPD FROM 701 MATERIAL EAIPL\CFAI ENT AIF.TI1nD&AMOUNT
ot N -WatcrSupjab-Well: D R. IJL ft. r
OMoniloring []Recovery
)njcctian 1Vcli:
❑A uiferRechat c O GrmmdAAalcr Rcmcdiation
❑Aquifer Storage and RCcovc OSalinil BARIef 19.SAND/GItAVELPACK Ira liroblc
ry y roots TO MATERIAL E51PLACFAIENTMET110D
ClAquiferTest OSlor uwatcr Drainage R. R.
OCvperimenlal Technology CiSubsidence Control
OGColhCnnal(Closed LOOP) OTraeer 1 20.DRILLING LOG faffileh additional slrzets Irnccessa
❑Geothermal(HPating/Cooling Retum) OOlher(explain under021 Remarks) FROM To orscmrnoN color IaN ns solFnckr a a: er>
(1. tr. 6 r' C
4.Date Well(s)Congdcicd:�_ -2 Z Wall IDN
So.1Vc11 Locali oil. P2I.R.C11MlfAMRKS
a.S R' ,�n,t..• ; r�gIED
S+Ct C (�� h�J ft. f,J -
Facilify/omen Nan+c Pacilily lDO(irapplicable) rt. JA N 0
o1y C61G /'Nl W,L y 2c 6t)1o,1 16)r 2�59 ft. Q23
Physical Addcss,City,ondZip If. I7Tii�s`I•^vP1 f :� ^�t�11:f
�-� A IC)'/I t
County Parcel Identification No.(PIN)
5b.L.7tltudc and longitude in dcgrceshsdnules/seconds Or dechuril degrees:
(irsvcll field,one tatllong is sufrreicnt) 22.Cer iliCfll 1:
N -7�.�D71��
6:Is(arc)lbc avcll(s): mPcrmonenl or CiTetuporary Signature ofCeulfned Well COMtactor -e Date
Opsigning this jams.l herebl,Cerro-that the"'ell(c)sras(roe)eaurnrered In accordance a ldi
7.Is this a repair to of existing well: ❑Ycs Or IJNo 13A NCIC 02C.0100 or l3A NC.iC 02C.0200 Well Cauuasrcdna starulantr aml drat a Colo.
•0111s a a repair,fill our bauv ur/l Consrn¢ton btrarnallan mud acplahl the nature ojthe ajthls ncvnl hat been prm•lded fa the sell a,amr.
reralr utOrr P21 rcmnrJa Seaton or on the back ojth0 jornt.
23.Site diagram or Rddilimtal well details: '
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having Ole same You may use the back of this page to provide additional well construction info
construction,Only I GW-I is nulled. Indicate TOTAL NUMBER of\volts (odd'Sce Over in Remarks Box).You may also attach additional pages irnecessary.
drilled I �n� )
Submit This GW-1 n ilhin 30 24.SUBMITTAL INSTRUCTIONS
9.Tutul vecll depth below land surface: d (R'
Faaw.Idide wells Nsaolldcpda ljd!/)crenr(example-Ja200'and 2Q1009 days orwell cornplctiol per the rolloring:
10.Suuic water level below lup of cusing: 2 (f) 241. For All Wells: Original form to Division of 1Vater Resources (DWR),
1j.ratrr le,l a obese cminy we"+' lnfonnation Processing Unit,1617 MSC,Raleigh.NC 27699-1617
11.llDMIlUiC dlauteler: (inn.) 24b.I/or InlcelioD 1V¢Ils:Copy to DWR,Underground Injection Control(IUC)
Rotary 11rogmnt,1636 MSC,Raleigh,NC 27699-1636
12.Well co.q.cable. method: 24e.Irar Wnlcr Su,d and O cn•Loo f Ge cruulr Relurtr ityclIS:Copy to the
(i.c.auger,hoary,cable,dirccs pleb,ere.) county envrronmenl0 ua hit department o the rowdy w Coln
e Ituw ern
FOR WATER SUITLY NVELLB ONLY: 24d.For Water%Vclis ,roduchn Duct 100 000 GPD:Copy to DWR.CCPCUA
13a.Yield(gpu) Atothod of IcsL Blow 1'cmut Program,1 1 ,Ina etg 1, 27 I
13b.Dismrectlou tYI,e: HTH Amount: 1 lb.
I'ww G1'1.1 Nonh Cwoiiun Depullneni of Cnvi,onu,ennal Quality.Division orl\'afcr licsosuecs
Rcvu<d 6-6.2018