GW1-2023-00894_Well Construction - GW1_20230120

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WELL CONSTRUCTION RTCORU(GW I) for Internal Use Only: �
L%1'e11 Contractor inrornintlon: i
Landon Phillips
14.1V.1TEI1ZONES
Well Connector Nome FROM To DESCH"'TioN
3441A 70
rt. rr.
NC"'ell Conuactor Certification Number
IV W Poole Well and Pump Company 15,OUTF:It CASING foe moiti ea+eel well+ GR LINER if o lirobtc
F80M TO pJA\1tTFn 7111CWtrSS MATP.RLIL
Company Nnmc f/ Ir. I 6/y I,- I & in.• r O hF, v
// 16.INNER CASING OR TUBING -thermal elated-too
2.Well Construction Permit I/: t7 �� FROM TO DIAMETER TIIICKNFSS MATFAIAL
l to a!!appNmble ur/!rn stir coon peroder p.e.111C.Cowl%Stole,Variance,era) ft. Ir. in
3.%VelI Use(check well use): ft. fr. In.
['3
er Supply Well: 17:SCRF.P.N.
ricultural FROM TO DIAADTFJt SLOTSrl.E TJIICKNFSS 51ATMIAL
OMunicipaVPublic IL a. in.
othennal(Hcating/Cooling Supply) C�aidential Water Supply(single) It. fbustrial/Commercial ORaidcnlial Wala Supply(shared)
18.GROUT
ation OWCIIS>100 000 GPD FROM TO MATERIAL EAU'LACEh1ENr AM1110D 6 AAIOVW
W.-iterSupplyWell: GIt2fLniloring ❑Recovery IL fLnjcction Well:
OA uifcr Recha a fl• fL
q rg OGrpundvvalcrRcmedialion
OAquifcrStorageandRaovcry OSalini Harrier 19.SAND/CRAVELPACK fa Iteable
ty FRO51 I TO AtATFJUAL EAfPL5CF�11L'Srr XMOD
❑AquiferTcst OSlorrrnvalcrDrainage R• I fL
❑Experimental Technology OSubsidence Control fr. ft.
❑Geolhermal(Closed Loop) ❑Tracer 1 20.DRILLING LOG Attach addit onalahcels ifnecaw
ryl
OGeothermal(HcatinglCooling Return) OOthor ex lain under H21 Remarks Fftol" I To DFSOt1PflON eoior.uaraaeu,aurarl,r .M,Iweea
o S
or-
4.Date Wcll(s)Completed: !U^/r/—ZZ WeIl IDIJ to r Is. I
5a.Well Location: 5— `t' ZG r,R.
Facility/Owner Nano facility IDO(irapplirable) It. ft
r7
I f4 R• i' � r.r
I J Cf clG�/cat (�G.i zi hcc�— VI17AIVOMOG
I'k-slical Address,City,and Zip
Ttrnn Ic(t i1 21.REMARKS
County Parcel Idciol cation No.(PIN) Used hardened steel drive shoe,
5b.Lnlitudc and longitude In degrees/ntinutestseconds or decimal degrees:
(irwell field,one lal/long is sufficient) 22.Certificali
--�5 SoZ��N - -� O- 3o]oD(a W
iu-rut-zz
6.Is(nre)(lie well(s): 011crmnnent or OTermporary Rgnaturo orCenirred Well Contractor Date
Ilyrigiing thisforot,l hereby eerdfy that thgvell(s)iris(ward cvtntructcd in accoodoace trirlt
7.Is this n repair to an existing well: ❑Yes or ItNo /JAI'GICO2C.0100or1SANCAC01C.01001r'cllCaatmcronStanJar&.Wllxfa",
!f this it a repair,fill ma bimrn troll construction 1r jorumtlonand explain the inure of de of this record har been prorlded to the umll ranter.
rgwir under#21 trniod s uctiant or on the back of thisforoa.
23.Site diagram or additional well details:
8.For GcoprobdDPT or Closed-Loop Geothermal Wells having the same You may use the back Of this page to provide additional will conuruction info
construction,only 1 OW-I is needed. Indicate TOTAL NUMBER of%velis (add'See Over'in Remarks Box).You may also attach additional pages irnecessery.
drilled:r 24.SUBMITTAL iNSTRUCrlONS
9.Total well depth below land surface: S (ft) Submit this GWA within 30 days ofweU completion
l°or ond0ple acrlr list oil depths Ifd�ercnt(erantlik.2 a 200'and 2 a@100� 1' per the following:
Z G ft 24a. For All Wells: Original form to Division of%Valcr Resources(DWR
10.Static water Ievcl below top of casing: ( ) Informnlion Processing Unit,1617 NISC,Raleigh,NC27699-1617
/f bruit level s a(rore earittg use
6 tab.For Infection Wells:Copy to D%VR,Underground Injection Control(IL1Cl
11.Ilorcbolc dimnctcr.' (bt.)
12.Well coustructiou method: Program,1636 h1SC,Raleigh.NC 27699J636
f30tafy 24c.For Wriler Su tiv and O en-Lou Geothermal Return Wells:Copy to the
(i.e.aagcr,Lowy,urble,direct push,tic.) county ellviromnemoI heal department of the county where installed
JrOtt WA'I'lilt SUI'1'LY WE 1.IS ONLY: 2441,for 1lhrter Hells arodudne over 100 000 Gill):Copy to DWR,CCI'CU:L
13n.Yield(gpnl) S blabod of lcsl:
131_OW \'crap Progmm,161 I MSC,Ralcigly NC 27699-1611
13b.Disiurerrion type: HTH Amount: 1 Ih' I
Four GW-1 Nonh Ctrolina DePaunenl of Iinvironal mal Qoality-Divistun oI%Voter Resource. Reviicd 6.6-10Is
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