GW1--02408_Well Construction - GW1_20240422

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I.Well Contractor Information' i.
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La(ldon Phillips tt a.1i1 N if1NFX— fi^
-------- --- --'- unlal ns _ IM11 fRNt
O'cll' Dxiias Na,,,, j 0 r, S n
ir
. Z`�e� /Y, •
3441 A ft, , FL 1
��Well •naarhn s sir,Oon Numitrl IS 11117 EU t ASC11( tbr multi cased will LrJR LINER et
NW Poole Well iitltl Pump C011lpitl1�' _ EMIR!+� 4m .2nmiTi '.na. 6:, _ t. I J^0
`•"•s;„..Nato'. r'/, / I6 INNER CASING OR TUR_ING(geothermal elnsed-Inup ' • 1
:.\\ell Construction Permit If: .1 i CI C2 Q t FN(Inl- in iLNIRI Eft T1uCJ(ae Y.4 MA1Ir�4R __I
,.,.. atAfr ovit„n,anu•ae,iv-rantsl e 1.111y m<bnna+.Vine,ra er,cu.1 V — ,—-_
~ft. ft. ie.
.1.Well 3 sc Owl,.well use): --`
---- 17.SCREEN
Water Supply Well: fItOM TO MAal(:I'FA -:11411 SIZE_. ,_rRICJPIVIS AtaTf Rral
\pi iculGnal llhlunicipahl'llhlic R. G. in.
L_VeotIlel:na1 Ii I ,tstg:'C'utrling Supply) Atesidentiat Water Supply(single) fr. b. in. --�
,7lotlust:ialiCommcre,al tJResietcntial Water Supply(shared) itt CN011'!
t`1.-rigutjon ❑\Yells>100,000(I'1) nonce TO MATERIAL £uirl.1C!_NLNT METIIOJ 1 AitOs.,.;: i
!Non-U'atrr Supply Well: O ft. .� R. ht/e p v _ _
C\tcnuoring °Recovery ft. ft.
1 Injection Well:
ft. tt.
..1.(wfs r Recharge OGrnundwatei Remcdiation --- --- ,
19.SAND/GRA VN1.PACK(if applicable)
_ -__-
1.)si cc Storage and Recovery ❑Salinity Barrier Foam TO MATERIAI. EMN.ACPMV.T Al ElIron
�.14u:ferTest OStutmwuterDrainage a. ft.
,1'spc,anental Technology ❑Subsidence Control rt. Is. ,
6e0i1':tonal(Closed L.dup) °Tracer 2U.DIALLING LOG(attach additional sheet.if necessary)
PROM 'ro DFSCn1rTION(tutu.-,hnranest,se,sUroex evpe,ersln sire-a,..
,s inter:;al(Beaus!!Cn,P.mg Return) Daher(captain under 021 Remarks) ft. 7 n t "r/�/�D;C
4.Mite Well(s)Completed: /6-1I/-23 \wit IDU a ft. 7' ft• • C�/vA V
p. J 5 ft. S4 ;• y. .
ia.Well Location: q � ,�..
f'Yle.f IIG (anon kS a- rt. V n� .'L.,. t..w .
//tt r'
FacilitylOwner Name Facility IN((if !.1 applicable) ft. f1. P R n!. : i 024
517 eat own P.el Z.e buIo1 rut a?sy? ft. ft.
Physical Addtus.Cityaid 7.i s rt, ft. t r..- .1 7_r
37)hn57/tJn 21.ItEMARKS it'IrI:':K.j. .
(sawn ParcelWanriticntion No(PIN) Used hardened steel drive shoe.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well acid,ant lat4mig is sufficient) 22.Certificad
3 5 '1ol\ g N - 1iS•2-15?,d .z ‹�
6.Is(are)the waifs): crnwuent or O'1•emporary, Signature of Ccnificd Wdl Cammdor �`' Dai<
Ityi�/,, fly signing,hu(.rter.I hereby certify thin she s.eil(4 sins(ten)cnnnn,aed n,elcto.;ba.....
7.Is this a repair to an existing well: OYcs or Y"a 15A NGtC 02('0100 ar 15,1 NC.IC U2C 0200 it'd\Cunrrn.rn.,Swift/firth raid that --...
if:his a u repu.r,f//out k„n.n owed construction afonnrnton and explain,lie nature/the .files rccnnf h 'hucn pnn•Id0/,n a.0 weal mruca--
re otr tower 1c 2I'mark strain nr on the lack of,6a f.ra.
23.Site diagram or additional well details:
S.Fur Geuprobc/DPT or Closed-Loop Geothermal Wells having the same you may use the back of this page to provide additional wed roes:ruutor e,:.
cons:ruction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ova'in Remarks Box)You may also attach additional pages if axes.
drilled.I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -CC.S (MI
Fur n.�.::ydc a,rih.'usa uldenshs fduf rent(sample-J(n�J00'md?n i0lP) Submit this G\V-1 within 30 days of well completion per the iof{owiug:
I(I.Static water level below tap of casing: Zo 24a. For All Wells: Original form to Division of Water R.:,.wc:s .0 •
(f1) Information Processing Unit,1617 MSC,Raleigh,NC 27ati8-InI'
;I a•nuutItad st sours•cu:ay,Its, -
241).For Injection Wells;Copy to DWR,Llnderrround InLlEaitasaC(utti,
I.Borehole diameter. 6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
Rotary
12.Well cunstructiva method:
24c.For Water Supply and Open-Loop Geothermal Retort;Werth::Copy au au._
i:.,.rotary.,chic.ditto p1.11,crc.) county environmental health department orthe eawety whet,:;rat d:,d
1 4k tt A I LB SUPPLY WELLS ONLY: 241 For Water Wells produeiue user Iaught CPD:Can). .J`A.ft,,,tcoa.:-
13a.•r icid'glint) ,lethud of test.
BLOW Permit Progrdlrr,1611 MSC,Raleigh,NC'li9i)-td:
i al,laisiutectiun type: HTH Antolini: 1 lb.
..,-a. Ninth Camilla Depwmtcut at Eavltuomcmal(fanny-Division ill Miler IteJoeasc.