GW1-2023-00901_Well Construction - GW1_20230120

t►�I%L,1,c(11Vg'i'(0,10110N ItI,CORD(GIV-1) i'o (internal Use Only; !!
L Well Contrmrlor Informnllen: `
Landon Phillips 14.WAT ER ZONES !
k6'r11 Cmmms",Nnme tROM TO Dr_SCRIP"ON
3441A GS fn• c{p fr. jlt
N('Well i'nnimanr r'nrrfreilnn NumlMr
15.OUTER CASINC. formula-emedwells OR LINER Gfopplicablel
NW Poole Well and Pump Company FROM I TO DIAMMIt THICKNESS I MTERML
Company Name H rt.1 7 f ft. & in. v ba f- C-7a Iv
/•� ��Z\\411 GOlittrlietlnn PCPmil ll: 1(,INNPRCASINGORTfRING .otermeawrl-lon
IAFh
FROM
TFRCKNE55 I M11ATER1AL
/.ar all npplimhlr meld cnnstrucrfan ptrmltt r,e,UfC Cmmto;State,Varforce,etc.) fL fl, in. .A*%r-
3.Well Use(check n•cll use): fl.
Water Supply Weil: 17.SCREEN.
OAgrictiltural MOM TO DrAWTI: slxyrsri:E THICK1,17M MATERIAL
❑Municipal/Public tL 4) ft. y in .a sc e—
catin
OGcol trial/ (l mercg/CoolingSupply) idcntinl WaterSupply(single) t/
OlndustlinVCommcicial It. f°• in.
OResidcntiat Water Supply(shared) 18.GROUT
Olen 3ti0R OWells>100000 GPD FROM1t TO MATERIAL EMPUC13rILWMEMOD& MOUINT
NOR-\Yatcr Supply N'CII: 611.
tL ] � IL
r^r�e �
Dhionitoring ORccovcry v M
Injection q'cll: B. It.
❑Aquifer Recharge OGroundwaterRemediation R• It.
OAquiferStorageandRecovery ❑Salinity Barrier 19.SAND/CRAVELPACK ife tfeable
FROM1I TO M1fATER1AL EM1TPLICE'i11UNTHEMIOD OAquifcrTest OSlormwatcrDrainage U fL 3Offt-
R3 (
OGvpeimcmalTechnology OSubsidcnccCentral (L fL
DGeothermal(Closed Loop) ❑Tmccr 20.DRILLING LOG attach additional sheeb If necessary)
OGeothcmial(11 iting/Cooling Return) ❑Other(explain under 1121 Remarks) 061 TO DESCRIPTION�ol�r.hnrdnm,walr«k in eau«u
0 a. a rL To .Sa
4.Date Well(s)Completed: l�i6 "ZZ Well IDq `ems t
$a Well Location: ED
IL 6T-11• 7.,, je
Fanliry/O,vrur Name Facility IDII(ifapplicable) tr• ft.
SS' Ca�lc�i L.h
r4loI(irkiw.J
Plomical Address,City.and-4 ft. f1. r i i
�jpn k/I t 21.KEMARKS
County Parcel Identiflcatioo No.(PIN) Used hardened steel drive shoe.
Sb.Latitude Ito¢longitude in degrees/minutes/seconds or decimal degrees:
{if tre11 Geld,oac IsUlong is sullieienQ 22.Cerlificati
35:�04-1�co N Jg- 3�� sa3 Kr
6.is(arc)the wcll(s): ❑Permanent or OTempor'ary Signatac 01Ucnrficd Well Contractor
fly sighing this jonn,Merely eenijy that the,we (s)tras(n erc)constructed in accordmice,rah
7,is this n repair to an existing well: QYcs or 8No /JA NGIC 02C.010o or i3A NGiC 02C.2o0 lYell Camtmedon Sraitdardr mad that a rnr
if dtnr Is a repair fill out toloun weir construction Information and explain the rwntre of the of this record hot been provided to the ue/1 otiner.
repair miler b21 remarks section or on the back ojthis jonn.
23.Site diagram or additional well details:
8.For Ccoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional nnll consMiction info
construction,only i GW-1 is needed, indicate TOTAL NUMBER of wells (add'See Ove'in Remarks Box).You may also attach additional pages if necessary.
drilled:1 ? 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3� VL) Submit this GW-1 within 30'dR For a sldpte%veils list all depdu yd�erent(eromple-3Q700'and 2©100') ys of well completion per the foitowing:
10.Sln6c water level below lop of rasing:_ 3 (ft) 24a. For All Wells: Original form to Division of Water Resources(DWR),
If iraterlevells obove casing,are'+" fnformalion Processing Unit,1617MSC,Raleigh,NC 27699.1617
11.Borehole diameter: 6 (ia) 24b.For lniccBon\Yells:Copy to DWR,Underground injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
I2.15'dl construction method.. Rotary
{i.e.auger ioLvy,wbte,dims push,dc.)
24c.For Water Su 1 and O en•Loo al Geotherm Return Wells:Copy to the
county environmentR health epanment of the county where installed
FOR WAT•L'R SUPPLY WELLS ONLY: 24d.for\Voter\Yells nroducin over IOU 0UU t 1'll•Copy to DWR,CCFCU:\
BLOW Penn 1'rogrnni,161 I MSC,Raleigh,NC 27699.161 I
13a.Yield(gpui) J hferimd of lest:•
13b,Disinfection type: HTH Amount: 1 Ib.
Fonu Gw l Nardi Carolina Department ofEnvirunmanlal Quslily-Division ofWaiar ltm,"cs Revisal 6.6-2013
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