GW1--03937_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Or11y:
1.W 11 Contractor lnformsfi n:
owkoml :;:
WellContractoorName FROM TO DESCRTIMON
ft. 22
ft. ft.
• I
NC Well Contractor Certification Number t�;pflTEti'!ASn�Ca formrilti-i a ed Sce1ls:fllt TT NE12i€ 'liratite...:: I
Miller Well Drilling FROM TO DIAMF.TF.R I TXUCKNFSS I MATF.RIM
Company Name
15<B�INFt2 CR1uVH �s`<Di`v`T L#BA301 >o66ffi<iiiafJCltaJSetStl`tuUG
2.Well Construction Permit 6: - 1? FROM TO I DIAMETER rH[CKNFSS MATERIAL
p RIAL
List all applicable well constnction permits(Le.UIG County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. fL in.
::;i;fifi:;::'::::Y:p%:>::;;::::is� %i:::.':F._S:»?::ri::.s;: ;;i::'G.p:: .;::`x;o-;•:;;>�»;;:;.::<•:�::o
Water Supply Well: s>3FSSrkEEPFii•::.:::::::::..:::..::>:::::::::::.::::..:_:.::::: ::.::,::•:::::::,:::. r>::>:: ;.::;.;::;:<•>::;;
FROM TO DI.4,IRTER SLOT SIZE THTCI.•1ve,SS MATERIAL
❑Agricultural ❑NQui�al/Public tt. fL i in.
❑Geothermal(Heating/Cooling Supply) DResideutial Water Supply(single) ft. ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
P. ,; ;i::SF:: i;;�::;i: :<;;i:>:::r,":?:;;::S::JR:;:�.�;i;C::Si ;`;:Si:S-:yr:;`2;;:::::;;::-:;;;:;:::::,�;,:•:.::
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL I EMPLACEMENT hfETTIOD S AllOTiKT
Non-ib'ater Supply Well: ft• ft• '�
t3•r n•-,. � vl I
❑Monitoring []Recovery ft. 2-0 ft. lork,\,( a
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :36iY3/tikx�1,PACLK.(if: icsble)
•
❑Aquifer Storage and Recovery OSalinizy Barrier FROM To MATERIAL EINIPLACE:VIEVI METHOD
❑Aquifer Test ❑StonnwaterDrainage
❑Experimental Technology ❑Subsidence Control
OGeothermal(ClosedLoop) ❑Tracer <>±0>Drt{6I1SG.L12::{ ttacnaddihiai<9 ibeets.r+ree�ssacv);r:> `;:•>: ... '
FROM TO DESCRIPTTO\(color.h.-loess,soillrocic tv e,erziasize,etca
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. 7�S ft. , aw 4- '��3 cC G
t
4.Date Well(s)Completed: Well ID# ft' [r 40 fr' ✓l,� a
5 Well Location: ft. ft. t �,,Y t r,
J nY ft. ft. ate. i V t,'..,.:
UfV
Facility/OwncrNamc Facility IDflifapplicablc) ft. fr. Jlln, y 1 9 n 3
J9 0t1Z r �oQ�L tG � f. ft. if
R. F1�.iiY i:.' �r . ..:,.,yc;.�ti a• ea
Physical Address,City,and Zip J ft.
_3..RC�JfA R
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degreWndnutes/seconds or decimal degrees: /
(it'e-cll field,one lat/iong is sufficient) 22. Ficatwz3 ° g•��, 9 W - =2z
6.ls(are)the well(s): OPermanent or ❑Temporary Signature ofC r e Wel. .ontrac or Date
B;signin,this form,I hereh cerrgj-that the m, (s)was Iwc re)cor rra•ted in accordance nith
7.Is this a repair to an existing well: ❑Yes or ENO 15.?NCAC 02C.0100 or 1S.4 NCAC 02C.0200:Yell Consin+crion Standards and that a cn/t;•
llj*dds Lc a repair,Jill ota/•nox z x•ell construction intonation and explain the nana-e oJ'thc ofttits recot•d has hcett provided io the uY11 owner.
repair under 921 remarks section or on the flack ofthis 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 construction info
construction,Only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You may also antich additional pages if necessary.
drilled:
i 24.SUBMITTAL lrtSTIPUCTYQ3NS
4.Total well depth below land surface: (- �I� ft-
)For multiple w if ells list all depthv di jerem(example-3 d�200'annd 2(5100') Submit this GW-1 within 30 days Of well completion per the following:
10.Static seater level below top of casing: D (qr� 24a. For All WeHs: Original form to Division of Water Resources (DWR).
ifvarer level is above casing,use '+" Lz10IInation Processing Unit,1617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter: (7 (in,) '24b.For Iniection Wells:Copy to DWR.Undergromid injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: F 1 n t kih(i.c,auger,rotary,cable,direct push,etc,) 24c.For Water Suy0v and®Den-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed .
FOR WATER SUPPLY WELLS(ONLY: 24d.For Water Wells nroducina over 100 000 GPD-Copy to DWR,CCPCUA
13a.Yield m f Permit Program,1611 MSC,Raleigh,NC 27699-16I 1
(gp ) O i_ Method of test: 1 7 I
13b.Disinfection type: T I Amount f'4 CUPP
Form G W-1 North Carolina De
partment of Environmental Quality-Division of Water Resources Revised 6-6-2018