GW1-2023-00944_Well Construction - GW1_20230120

BAN 2 0
1VGLL CONSTLWCTION 1�l.COlt1�(Gib'=1I) for lnlcrnai Usc Utley: i At,
1.Wdf C'onlrnelm inrormmtion: r�r
`ill
Landon Phillips
_ IJ.IVA7F.RZONES
Well 17w,nim Name PAO}S i0 UISfRrrT10N
3441 A
h. n.
NC Well Contrxio:CeniRes]ion Nutulicr
NW Poole Well and Pump Company IJ.OUiF.R CASINO for muld•cmed ntlb pR LiNER fa Ikobia
IR0.51 TO UTAMl.TEn 'THICKNCSS AtATER1AG
Cmrynoy Nowe _
'• 'n Tr\�r J 16.INNER CASING OR TURINO eolhernml rtnttd•lao
2•Well Consfrucilon Penult q:_W�( ( ( Host O DIAA1GFCn •TIIICKNE33 ArATIRIAL
N't 0 amol, Me aril co-ln.ennn mdu c.UIC,C'xar;n h. ft. la
!Y (J� D rile.I aNent4 art.)
3.Wei Usc(check well u3c): ft. rr. la
Water supply Weil: 17.SCREEN
a911 U DI 51 PR t.OTrI/.P KNFSS MATERIAL
❑Agricultural OMunidpal/Public ft. ft. In.
❑Geotlicmnal(Ileming/CoolingSupply) kesidenlial Water Supply(single) n. n. In.
OlndllstriaVCommcrcial ❑11csidentiol Water Supply(shared) IS.CROtrf
❑Irri anon OWelis>I10000GPU 11.11 TO MATERIAL EA1vra r E, n - ImDdAnt
Non-Waler Supply Well; ID
ft. ft.
Ohlonitoring ❑Recovery
lnjectioi \Yell:
OAquifcr Recharge ❑Groundwater Rcmediation ft. ft.
19.SANDIGRAVELPACK(Ifunalicablel
OAquirer Storage and Recovtxy OSalinity[farrier FROM TO MATERIAL I EtUruCEVENrmeniop
0Aquifcr7'cst OStormwalerDminage n. n.
❑Ccperimenlal Technology OSubsicicnce Control n. ft.
OGeolhcnnal(Closed Loop) 0 Fnccr 2D.DRILLING LOC attach add]Nonni sheets Irntcuta
OGcotlicnnal(HcatinpJCooling ltcllum) O011ur cv lain under N21 Remarks ERmm To uEsclurrIONtarot hmrdnesr 10111mltlnrlu.elf.
ri.ft, �OrrL
4.DifeWeli(s)Coinpletcd: ,RV Z WellIDN ff. n. CA,V
So.Well Location:
S+Cx r G)n5f' jollm
haciMy/Onrcr Nana: Pncitily IDO(ifoppliwble)! rt' fl•
�d L 5 4ccrt+ar�at Worf Ghana( 14I11, ta7S(
Physical Addicss.City,and Zip n, ft.
21.RF.p1ARICS
County Parcel Identifcation Na(PIN)
Sh.Latitude and longitude in degrecs/minutedseconds or dcdninl degrees:
(irvmll field.one Iatflong is sufficient) 22.CertilicnI
3�.q 511�1 N alU�ln3 W
-Zll-2
6.ls(arc)the well(s): ®Pcnunuent or OTemporary signarotoofCcniRcd wou COaVaelar , Date
Bysignbig IhG faro.I hereby cep jynat du uell(.v)u•ut 0"reJ eoiutnaled In oeeo amree rridy
7.Is this a repair to an existing iveli: Oyes or 0No iJA MIC 02C.0100 or iJA NCiIC o2C.o200 II ell Calutnrction Stmrdanh mul that a cap)-
ifihts Is a repair•fill aid kno unrdl emumuctIon lirfmnallon mid orplohl Am name of ilx efih6 record hat been provided to Ike well writer,
repalrmuler ell rernnrk secdar or on the bark ofthtr font
23.SIIC diagram Or nddlli011aI\YCII details:
8.For GcoprobrJDPT or Closed-Loop Gcotliennnl Welb having duo some You may use ilia back or tills page to provide additional well construction illfo
collstfuclion,only I GW-I is needed. Indicate TOTAL NUMBER orivalls (add'Sec Ovice in Remarks Box).You may also attach additional pages irnecessmy.
drilled' 1 J/e'� 24.SUBMITTAL INSTRUCTIONS
9.Tutal well depth below lnud surface: / YY (rl•) Submit this G�V-1 wllhin 30 days of vvdl Foraade pre falls hit all deptlu t(dli facet(eromple.J@200'oud 2QI007 y completion per the fonmving:
10.Static water level belovr lop of casing: 20 (ft) 20. For All Wells: Original Conn to Division of Water Resources(DWR),
rTuatrrin•d!r obm•e toting•rue•'t^ Inforination Processing Unit.1617 MSC,Raleigh,NC 27699.1617
11.Borehole diameter• (in.) 24b.For iniection Wells:Copy to DWR,Underground injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
1..aardl constnable, ma push, 24e.For%VoterSuu 1 and Open-Loan Geothermal Return Wclis:Copy to the
(i.c,auger,rotary,cable,dircd push,etc.) comity environmental licalth department o.lTie county w tare msm
FOR WATY.R SUPPLY Lp ONLY: 24d.For Wnler\Vdis roducin•over 100000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpni)�_Method Priest: BIOW Penal 'rogmm,I 1 I C,Rn olg 1, I 1
13b.Disinfection type: HTH Amount: 1 lb.
lam G15'•1 Noith Cmolinn Dcpslrmeut of EnviiomneNol Quality-Divkian or Wnler Resources Revised G-G•:O18