GW1-2023-00898_Well Construction - GW1_20230120

\1'dsd,I,( nA'ti7RT1CTIOdV RrCOd211(rov I1 For intcrnat UMeOnly
7.R'rA Cantrnrtar Infarmndan:
Landon Phillips
4ve11 Cnrarnetar hlaa a 14.1VATER ZONES
FROM TO I Dr_SCRtMON
3441 A Sir• al�G rr.
R'C N'rll Cmm�efar Crrtifica(. 1.157J n- R. rC;.
tan Naml.cr
NW Poole15.OUTF,IICASING for mall-eased wells OR LINER do t7cable
Well and Pump Company ,-no., TO OfA81CrrA TniG7a M ,IATERtAL
Comlrany Name pd h. G/( ft. (0 in, iO 2 V, GTAf V
Well(• lG.TNNF.R CASING OK TIIDINC, eothern ml cirmd-fon
onsiruction permit l/: Co O 12.(@ FR0,17 TO 1 DIAMETER TIIICKPIMS )UT4RIAL
Ltsr a0 applGrohfe urn/raartrexnnn pumas It,!.IHG Cwmry:S7atr,7'ortanre.etc.) fL ft. in. ,
3.Well Use(check,elf Ilse): ft.
Fee
r Supply Nell: MNCDlluml DIAtiMUR SIA)MI.P. TitICTCNTSS MATERIAL
OMunicip"IMblic thermal(Healing/Cooling Supply) 70csidcnlial Water Supply(single)
strial/Commercial / IaORcsldcntlol�ValcrSupplyh anon OWclls>100000GPD SUTLRiAL GSipLACG1TytIrSlETAODSAMOIJ1vTnterSupply Well. r MATEitoring ❑Recoveryn.
ion Well:
ifer Rechar a .E []Groundwater Remcdialionfer Storage and Recovc 12SAND/GRAVELPACK ire livablery []Salinity Bartier FRO51 To MATrotArEh1PFACE�fiV1,1IErIlODfcrTest OStormwalcrDrainage IL fa
rfinenlalTcchnology ❑SubsidenceControl emtal(Closed lAop) OTraeer '20.DRILLING LOG ntt2 additional sheets ifneceasa
❑Geothermal(}!eating/Cooling Return) []Other(explain under 021 Remarks) FROM To DFSCRIPTIONcolorherdnrmwilirack larrrr.ctc
6 R. ,I rt. to
4.Date Well(s)Completed: Well ID/I .a fL 7 fL SPAI/ —.
5'L Well Loca(ion: a'? IL Gd! R. C7rp fG ` M f
Facility/Owner Nam; Facility IDN(ifapplicable) ft. ft.
Physical Address•City,and Zip ft. fL A
21.REMAItICS
Comfy Parcel Identification No.(PM) Used hardened steel drive shoe.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one ladlong is sufricient) 22.Cerfiric ti
35'105()3 N � 78.3h�a(�I W
lO- 3-az
6.Is(ari)the wc1l(s): []Permanent or []Temporary Signnlurc ofCcnirred Wall Conuacfor - Date
0y V911hig this form•1 hereby cento that tha re/1(s)um(trerr)cowlructed ul acmrdmree trah
7.Is this a repair to an existing well: []Yes or CINo /JA NCAC 01C.0100 or 15A NC4C 01CA200 IP011 Conitrvcdot Stardlardr and that a mpr
1f this is a repo/%fill oat biou'n well ebrurntctlon h jormadan and explain the nature of die of this record bar been provided to the me/t ouster. .
repair under e21 remanla section or art lire back of ddsforor.
23.Site diagram or additional well details:
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the 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 (add'See Ovice in Remarks Box).You may also attach additional pages if necessary,
drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r0 (R.)
Forundriple weir Itstall depths jd1rerent(example-3�00'and2Q100� Submit this G1V-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top ofcasing: Z G (ft) Infomtntion Processing Unit,1617141SC,Raleigh.//trmcr ferel is above mslnR use"+" g g.NC 27699-1617
I I.Borehole diameter' 6 (in,) 24b.For Infection Wells:Copy to MR,Underground Injection Control(IUC)
Program.1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary 24e.For WnterSupDly and Open-Loop Geothermal Return Netts Copy to the
(i.e.auger,totmy,cable,daw push,etc.) county envimRWr,_ l health depanmcnt of the county where installed
FOR NVATFIt SUPPLY WIi1.LS ONLY: 24d,For Water Wells Droduclne over 1(2 000 CPD'Copy to MR.CCPCUA
BLOW Penn it Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(glum)_ U Method or test:_
13b.Disinfection type: HTH Amount: 1 Ib.
Fmw(iW 1 North Carolina Department of Eavimmtcnlal Quality-Division of Water Resources Revised 6-6.201 a
i
I I
i
� I