GW1-2023-00899_Well Construction - GW1_20230120

ffl; ,1,CONSTRUCTION R).C)M)(Mil-I) f or intemel Usa Only:
I.Well Cnmrrrtn,lararmaman: I I
Landon Phillips 14.WATER 7.ONFS
11'r11ll.Nn.1,- FROM I TO nr_Stn[rrtU;',
34 41 A j S rr. o n- /o 121-
rc P.W:cma r,M crnire,dna xnmlxr 3o R^�
NW Poole Well and Pump Company ts,otrreR cnstnc for multi eased relt.OR LINP.R,ro 14able
FnUM TO DSAMCrER TIItC 1tATTAIAL
I Company Name I-( ft• q e,D.
S �' t6.INNER CASING OR Tt1RiNG mrhermaldmed•Ioa
I.\fell COnrfructlon 1'crmil(I: "0.11 TU DIADILTF.R TIIICKNFSS ]tATr3lL1L
!!.rollop/w9rnAl�vel7 rnnurvrrrnn pnm,u p.e.O1C,C_%Sra1.Paris . M.) R• fL is
3.{Yell Use(ehecl.oral!ure): f6 ff. hl.
' \1'Rtrr Supply\\'ell: 17.SCRF.F.N
i OApricuhtural ❑Municipal/pub]ic ERos To mnMr;rER sL rsrtR TrncRNrss MATERIAL
❑Geolhermal(H©tinglCoolhn Su I ( fL (p�rL 6 In. .I S' pVG
B pp y) idcntint Water Supply(single)
Oindustriolcommemial m• rr. In.
❑Rrsidcntinl 1ValerSupply'(shared)
' ❑lrri alion 1D.GROIIT
❑\Vells>1000DD GPD {ROM TO a/ATERiAL F.\IPI.\CF.VENr,1IF.rImDA AtilO1M'
Non-\VnicrSuppiy\Yeu: n. 3 rL
i CMpnitoring ❑Recovery
Injection Well: Is. It.
I OAquifer Recharge ❑Oroundwotcr Rcmcdiation ff. It.
0Aquifer Storage and Recovery OSolinity harrier 19,SANDIGRAVEL PACK f R 11-ble
OAquifer Tesl FROM To n1ATT:mAL EM1IPL\CEafE,T MEOrOD
❑StormwalcrDrainage O rL a(0TrL t
OGperimcnlal Technology OSubsidence Control r
v OGeathennal(Closed Loop) rL D,
OTraecr 20.DRILLING LOG atmeh addir000l sbeets If neensa
OGcothcrmal(HcatinglCoDling Retum) OOther(cx lain under f121 Remarks FRO51 TO DESCR MO.-, amr,Erma.r.,aa ach, u,,r,nr
t4.Dole{Ycll(s)Completed:rU_ {Yc111Dfl�_ R, 3G fL ..JD
So.Well Location: 4 A,.ef[,
a 0 'S'J Iran, G
n• a � l
u ra�c�lry�lO.vt�m Name/ I Facility JDa(i(ifapplicible) ft. ft. (�
ED
R --riu_r��f�C/r�`/e n/' 7n6LA 01 Y`L• R. rL Lf��
y Plrynrat Address.City.and 2,p rr
_t 4,c r, -�'IV\ 2y.REMARKS
County -c. , -"•, UM
Parcel ldcttti 1cation No.(PIN) Used hardened steel drive shoe, r L s.
la iy�/ C,7W
Sb.Latitude and longitude in degrccslmtnuteslseconds or decimal degrees: /(ifvvell field,one ladleug is sufficient)
r _3'1 �0�0 2 �r-KJ 22.Ccrlificn0
f 521 N (S W
all
6.Is(are)the well(s): OI'crmnnent or O'femporury Stgnalum ofC<nificd Wdl Conunctor //G^Lam_
S Datc
7.is this n repair to an existing well: Oyes or N1'=r&'r/r'C IG»forru,l rrerrbyeen fy drat rGa nrN(rJ uvu(u rorvrnrcrcd tr nao�rxe Irirh 1Jd16(s o«pal"'fill our brmen'tell eautnicrion i fom,ndon and d plain the ranee of the -0111«ca d2har.0100
b e a pinor t�de�Ca nr l a ll'elf Cmusrvcrion Srma1v06 and Jurt a mpr
rgnb m,der Bll«nmrla secdm,or on she back ofddsform.
°0 23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page io provide additional well construction info
,b.I construction,only lGW-lis needed. IndicaleTOTALNUMDERofwells (add'Scooveein Remarks l3ox).you may also attach additional pages ifnecessary.
if vn drilled:
2
9.'Co(al well depth below land surface: (�y S 24.SUBMITTAL INSTRUCTIONS
fa ((L)
r nndnp vdtr lr list ull deeds Jel((ercm(example•dQ2 0o'and2Q10a� Submit this GW1 within 30 days Orwell completion per the rollow9ug..
f D.Sialic water level below lop of easing: G (fL) 24a,For All Wells:Original form to Division of Water Resources
If l: lfuara fete!Is above rarrrr�use•+" lor"T ation Processing Unit,1617 h1SC,Raleigh,NC 27699.1617 (D1VR),
1)di, 11,Borehole dimnelcr:6
«rw (in.) 24b.Eor Injection Wells:Copy to DWR,Underground Injection Control(IUC`
Rota Program.1636 MSC,Raleigh,NC 27699-1636
8.1 12.Well construction method: ry
,on (t.e.at'C<r,roWy,cablc,di,cet puslLctcJ 24e,For\V a'" 1 and O en•LoO W
Geothermal Return ells:Copy to the
dill county cnvuonmcnlal health department o the county where inttall<d
7rUlt\YA'1'1;R SUI'1'LY WIi1.LS ONLY:
9.' 2•1d,For Wnlcr\Yells roducin Over 100 D00 GPD:Copy to DgrR,CCPCUA
l:a, 13a.Yield(gent)_ Method=lb.=
I'crmlt Program,1611 MSC,ttalcigh,NC 27699-I611
10 13b.Disinfection type: HTH A
rJ'
t1 •
Fom,GWA NOnb Carolina Deprttmenl of Enviromnemal Quality•Division of Water Resotuces
I.
1 L Rcviscd 6.6 201 a
FOR WAVT It SU c
PI'I,Y W EL S ONLY: 24d,'For\yutcr\Yens nronucu,K
13a.)'IcW(girt!) Mthud ur test:
BLOW I'cnml Program,1611 MSC,Raleigh,NC 27699.1611
13b,ly)slnrecltau typr.NTH Anwmd: 1 ��'
1'umt GW-1 Nato,Cx,olins[hputmcnl of Envirotuncmal Qoelily-DMIi.t of W ate,Itesomccx R<vi.,16.6.201 s
I