GW1--03973_Well Construction - GW1_20230612

ALL CONSTRUCTION RECORD QW-13 1 For Internal Use Only: �
i.Well Gontractor Information: l4
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(� 2�l F►'7j 14 sl�£'1 EkD a�9.
FROR! TO DESCRIPTION
Well[,C{0ont�trrraacttoor Na
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NC Weil Contractor Certification Number 1 {gtyTE4 C`.F1SaiYC<!£cr.rtsuYa sas d e r3S�.L11EI dzklf.3'itfcebta....,
Miller Well Drilling
FROM TO DiAXRTF•R THTCKNFSS MATERIAL
Company Name f ft. I /, in. L3Y F 2 l i
'6sa'l dFtC1?6SGFDt`-&glBSchYx:: evrtiingt.rtasetttub `
Z.Well Construction Permit irr' - FROM fO grAMba'K)t THICKNESS NIATP:RIAI.
Lisl all applicable-,ell constnrction pennils(i.e.UIC,County,S(ate,Variance,etc..) ft: It. in.
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3.Well Use(check well use): fc. ft. rn,
Water Supply Well: !.. .....
FROM TO Di.4mr-ER SLOT SIZE I THTCKYESS 'MATERIAL
[]Agricultural ❑Nfuly 'pal/Public ft. ft. in.
❑Geothermal C'riearing/Cooling Supply) L'fFcesidential Water Supply(single)
Ellndustrial/Commercial ❑Residential Water Supply(shamdi)
❑Irrigation ❑Wells>100,006 GPD. FROM TO MATERIAL I FNIPLACF.MF.NTNfF,THODSA\rODNT
Non-Water Supply Well: fe. fr•® Of
Pumv ad
❑Monitoring ❑Recovery '7 ft. � ' ft. '
Injection Well:
ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19s:S1zNI31(3:Rr: ELPACX-
❑Aquifer Storage and Recovery ❑Salinity Barricr FRoIU TO MATERIAL CFM NT NIETHOD
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑(Jeothermal(Closed Loop) []Tracer 2fr:t}RIi3FP9�^�I G f ttzca3aait®nelats ii ecesas v ...:..
(Heating/Cooling ) "01 Remarks) rR hl TO DESCRIPTION(color,hardaess,soillrock ty a erzin size,etc.)
❑GeothermalReturn �y❑Other(explain under l} ft. ft.
4.Date Well(s)Completed: -I // Well 1D# v €t. 2 f.
5a.Well Location: 99 te-ft. �� fr. CI c e ....
ft. ft. 4.. �
i
Facility/OwncrName Facility'lb#(if•applicable) ft. ft. UN-
j.F',1����'i � c➢
Physical Address,City,and Zip ft. ft. , r(3::°.:i R*4 W r
� ra
County Parcel ldcntification No.(PIN)
5b.Latitude and longitude in deb ees/ndnutes/seconds or decimal degrees: -- i
(Ifwell field,one lat/lon,is sufficient)
22.Cer•icatio
6.is(are)the well(s). ermattent or ❑Temporary Siytature ofCertiu"ad ell Contractor Date 2y
�� B�rignin,�!Iris Jorn:,1 F,erent'nrr7!/�7Jtar Ihr v.t+JJ(..y wz!•t(wet•+)�urralru<•re;l ir.aeccndrmce nz!h
7.€s this a repair-to.an exist-+^.-,well: ❑`�•es or A?s�d'o -- I5.4 NFAC 02C.01 fir)n;•17 NC�C(1?C'.!I200! IJ Cohstn:crion Sranr mds and that a cnn1•
If'rhGs lc a repair,fi/!our fnoxa xell cons!nrc!ion iafbnnariat and explain the ra;rue of`tkc, of!his record laas freer,provided ro the-cell oivner.
repair under,"21 remarks section or on the hack of shis.form.
23.Site diagram or additional°,veil details:
8.For Geoproba/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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:
j y�fi,) 24.SUBMITTAL Q'STRUCTIONS
9.Total well depth below land surface. 0 (ft)
For multiple wells lisr all depths•if d jJfereni(example-3 a 2a000'and 3(d1 firi') Submit this GW-1 within 30 days of well completion per the following:10.Static tivater level below top of casing. 1-�d J (ft.) 24a. For Ali Wells: Original form to Division of Water Resources (DWR).
If-cater level is above c asbry use"+•• lnfOIInaliOn Processing Unit,1,617 MSC,Raleigh.NC 27699-1617
11.Borehole diameter:��- (in.), 24b°For Injection Wells.Copy to DWR.Underground injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
e�Btell construction'method: 9Otar
0 F 24c.For Water Supply and Den-Loop Wel
Geothermal Return Welds Copy to t(le
(i.c.auger,rotary,ca6m,direct push,eta.)) county environmental health department of the county wfiere installed
F®12 CIA➢EIZ SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 G1P :Copy to DWR,CCPCUA
13a.Yield(-,pm).� � Permit Program,1611 MSC,Ralei=h,NC 27099-16112
ls/Iethodoftest:
13b.Disinfection type: Amount: 1
A (AJR
I
Form G W-]
North Carolina D".artmeiit of^Environmental Quality-Division of hater Resources Revised 6-C+•_'Ol S
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