GW1-2023-00911_Well Construction - GW1_20230120

WE,1 1 CONSTRUCTION RLCORll(GW-11 Fof(ntcrnal Use Only:
I.well Conlrnclor inhtrnmlion:
Landon PhillIPS 14.WATER ZONES
FROM To DESCRIPTION
Well Contmom Nana fl. C/1 f- ft.
3441 A n. c jPg D.
NC Wdl Conuaclol Cemification Nundus is,out ER CASING for mu I Cott Its OR 1.(NER i(fuDPlicable
NW Poole Well and Pump Company Fnobl To PIAM"ER TIIICKus 51ATERIAL
In a d r- C t
Coatfeu)-Naive c�1 16.1NNPR CASING Olt TUDINC eolhermni closed-loo -
2.\Veld CouitrCllOn Permit t1: FltObf TO DIASIfrF.R TIIICKNE°S MATERIAL
l.tn oil aprJhn5le vr71 ton*nYKNnn pemnhr(t.A U1C,Cmnht};Stole,Variance,tic.) h, fl. in.
In.
3.\Yell Usc(elieck n•eli use): 17.SCnF. N
Writer Supply\\'CiL• F11051 TO I DIAMETER I SLOTSIZ►, 17111CIMUSS I 51ATERIAL
OAgricultural ❑M ipal/Publie ft. D. in.
OGcothermal(Ilcaling/Cooling Supply) III desidential Water Supply(single) D, D. In.
Olodustrial/Commercial OResidentialWatcr Supply(shared) 1&CROifi
Ohri ation OWells>iDO000 GPD FROM TO MATERIAL F.AM CE.\IFRr 51RDOD&AMOUNT_
Non-WalerSupply well; �ia
❑Monitoring ❑Recovery R. ft.
Injection Well: ff. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK hfa Iien6le
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL E1IMACE51LYr51MIOD
CAquifcrTcst OSlommaterDminoge R. ft.
C13%perimental Technology ❑Subsidence Control fL ft.
❑Gcolliermal(Closed Loop) ❑Tracer 20.DRILLING LOG allaehaddlDonal sheets If neteva
❑Geothermal(HeatinglCoolingReturn) ❑0dur(explain under421 Remarks) 11HOM To Desenll ON fialu,hoNnev ratVmskir e. ' ar
pO fL CV Sa
4.Date Well(s)Completed:7_�n-w \Yell IDfl p, ft,
ft.
Sa\1'cll Location:
p��' s fl. fL '.I
u- ED
Faclity/Ossner Lane // Poeility IDO(ifopplicable) ft. ft.
Y19 JAN Cu lel,nr• C—1 tic ZP " n(. R. ft. 23
Physical Addmss.City,to ip n. D.
21.REMARKS �+' "'.e °'�VI�
WIWI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrecs/mhmlcskcconds or decimal degrees:
(irsvdl Leld,one htwong is sulneient) 27.CCr1lDcnl .
.�5•°10515U N --79e 201 nil W 1
6:Is(arc)the svell(s): 19Permmnenit or ❑Temporary SignatureorCenined Well Contractor e Date �zL
Op signing tlds jonn,thereby eertf•that the weli(s)tray(acre)rormrucred in accordmrce a ith
7.Is(his a repair loan existing well: ❑Ycs or IMNo 15A NCAC 02C.0100 or/JA NCAC 02C.0200(t'eil Cuiutnictiati Steadmfs mxl ilia,a copy
if this is a red ai,fill our k++oiru yell ro+urruction b jormatnn and explahstha rmture aflhe Ilihis retard/kit been provided to ibe well mrnrr.
repair under 1,21 rearm{:,xectia)i or air tm back ofihb form.
23.Site diagram or additional well details:
8.For Gcoprobc/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 Ovee in Remarks Box).You may also attach additional pages if accessary,
drilled- 1 24.SUBMITTAL INSTRUCTIONS
9.'Total well depth below land surface: �G (R') Submit this GW-1 within 30 days orwcll tom
l-orhmdaphr rrel/distall dephhs%dprew(example.3@200'mhd2Qf00) y pleldon per the fallowing-,
24n. For All Wells: Original form to Division of Water Resources (DWR),
10.Static n'ater level below lop of easing: (fl) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If a ater Irrrl a abort eroine.use"t"
I.Borehole dlmuelcr: )C19 (11i 2411.par Infection Wells:Copy to DWR,Underground Injection Control(iUC)
Progmnl,1636 NISC,Raleigh,NC 27699-1636
Rotary
12.Well cous(ruc(ion method. 24c.For Wvulcr Su nlily and O en-Loa Gcolherntal Return Wells:Copy to the
(i.e,oogc:,cowry,cable•discct push,cic.) cowry environmental health department o t o county w era costa e
FOR WATER SUPPLY WELLS ONLY: 24d.For\fader Well mducln over 100 000 GPD:Copy to DWR.CCPCUA
13a.Yiehl(gym) Blow 11cmut Program,1611 C,Ida cig 1, C 27 611
a n Mclimd of test:
)3b.Aishdccilon Iypc: HTH Amount: 1 lb.
I'unn Gt5'.I Nettb Ctuulina OepuOnent of Huvhrounwntai Quality-Division of Water Rcsoutces Rovised".2018