GW1-2021-03403_Well Construction - GW1_20210607

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WELL CONSTRUCTION Rl RD(GW-1) For Internal Use C'
1 Contractor Info r ation: �� 6�,�
Q Y 9 14.WATER ZONES
Well Contractor 11ame 2�21 �� ��
/// f' rr FROM TO DESCRIPTION
�3 J u N X I ft ft.
�� y
Unit ft. ft.
NC Well Contractor Certification Number pr0�0S81I1g
Inf�r�,,�t1on �J8Cti0n 15.OUTER CASING for'multi-cased wells OR LINER if livable
Miller Well Drilling DWR FROM TO DIAMETER THICKNESS MATERIAL
ft- ft. in. q �
Company Name L
16.INNER CASING OR TUBING eo�ithermal closed-loo '
2.Well Construction Permit#: D wVCJO FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL fr, in.
I7.
Water Supply Well: SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fi-
Monitoring Recovery fL 20 ft.
/1 u
Injection Well:_ fa ft.
Aquifer Recharge E]Groundwater Remediation 14.SAND/GRAVEL PACK if applicable)
q g ry ty FROM TO MATERIA k
A uifer Storage and Recovery Salini Barrier L EMPLA 11 CEMENT METHOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessa
'Geothermal(Heating/Cooling Return) _. Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.
ft. � ft.
4.Date Well(s)Completed: ZZ-2 I Well ID# 38, ft- f1. ,' -
Yell Location: 65 f, 3iz)ft. r
ft. ft.
F�(ac�iljity/Owne ame ft./ - Facility IDD##(if applicable) ft.
V O f/l///l9tZ h70_ 1 �—/I ft. ft.
P cal Address,City,and Zip ft. ft.
21.REMARKS s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35odd. N OFY° I7. oal w AvWegd— l-2z-z
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
� By signing this.fornt,I hereby certify that the svell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or _ with 15A NC'AC 01C'.0100 or 15A MCAC 02C.0100 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under @21 remarks section or on the back of this form.
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: c�W (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@a 2000''and 1@100') construction to the following:
10.Static water level below top of casing: l )o I (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Injection Wells: In addition to sending the form to
JR
the address(es) above, also submit done copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the countyUlu y
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
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