GW1-2021-01515_Well Construction - GW1_20210309

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WELL CONSTRUCTION R:..-_-'ORD(GW-1) For Intemal Use o,cry:
1Contractor In
i
i 2ry� 1� 14.WATERZONES
FROM TO DESCRIPTION
Well Contracto Name
f `` fL / l
r/ / ft. ft.
NC Well Contractor Certification Number 15..OUTER CASING for molti-ca5ed wells OR LiNER{if a licabte
Miller Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
r / "
Company Name ft. 2-7ft. in. S fT ;0/ ` t
� O'�J10 � � 16.INNER.CASINGORTUBING geothermidcltossed-loo
2.Well Construction Permit#: I . FROM TO DIAMETER THICKNESS MATERIAL
1J.vi tilt applicable well construction permhs(i.e.I//C,CounOy,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fa ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSI7-F. THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft, in.
:)Geothermal(Heating/Cooling Supply) R idential Water Supply(single) R. ft. in.
Industrial/Commercial nResidentiai Water Supply(shared) 118.GROUT
Irrigation FROM TO MATERIAL EME,ACEMENT METHOD&AMOUNT
Non-Water Supply Well: r ' ft. ;/ ft. Tic
Monitoring DRecovery 1 /
Injection Well: 5.. U /I Ytt7r v_ t v11 17��J
ft. ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PA.CK if applicable)
Aquifer Storage and Recovery OSalinity Barrier . FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test t `OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/CoolingReturn) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrockt °rain size,etc.)
ft. ^ z ft. /GV r /le'�
4.Date Well(s)Completed: f� 7 G� Well ID# v�; ft � () ft. (7i27./�t,t'c'-
ft. ft.
5a.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/y Y i�5 YAa,i) ft. ft.
Physical Address...City`and Zip ft. ft' Information Processing Unit
`� rJrJh(ltt'(eZ.���t� 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)evi rmanent or OTemporary Signature of ertificd Well Contractor Date
By signing 1hi.s form, I hereby certify dial the well(s)was(Were)c•onsinicied in accordance
7.Is this a repair to an existing well: E]Yes or �o wish 15A NC:AC 02C.0100 or 15A NCAC 02C.0200 Well Consiniciion Standards and that a
{f this is a repair.ftll out known well consintoian inf>rmaiton and explain the nature gf the copy of This record has been provided is the xe/1 owner.
repair under:21 remarks section or on the hack gjihis farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction.only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: yy'^^, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .;ylJ (f-) 24a. For All Wells: Submit this form within 30 days of completion of well
/iu•nudrip/e ti e/Ls/i.cr u!/depdu rjdijjerent(eranip/e-3@200'and 2 a.100') construction to the following:
10.Static water level below top of casing: b (ft.) Division of Water Resources,Information Processing Unit,
114ater/ere/is above easing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
� d/) �, /1 above,also submit one copy of this form within 30 days of completion of well
8� C/
(i.e.
Well construction method:.auger,rotary.cable,direct push,etc.)) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: hr 24c. For Water SuoDly& Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: '� Amount:_�[t1 C'C)� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016