GW1--04418_Well Construction - GW1_20230710

PnntForm
WELL CONSTRUCTION RI .)RD (GW-1) For Internal Use G
1.Well Contractor Information: i .
ZKV cl RPZCz.e- 14.WATER ZONES'" - , . .
FROM TO DESCRIPTION
Well contractor Name U 4Cr.ft. t.j ft, C i t i`t/
ft. 0 • ft.
• NC Well Contractor Certification 'on Number
°15.OUTER CASING(for multkased,wells)OR'LINER alai) licable) -'
Miller WeII Drilling, FROM • TO DIAMETER THICKNESS MATERIAL
Company Name l-/ft. I J q``ft. (h 'in. S'D 2/ pvC
jj ,, � //'� tt / }/� . 16.INNER CASING JOR TUBIN�G4tfeothermal closed-loop)( . ..
2.Well Construction Permit#: W2Li 2 'L-\6155, FROM ' TO • DIAMETER - THICKNESS MATERIAL
• List all applicable well construction permits(i.e.UK*.('aunty.Stale,Variance,.etc.) fL' ft. in.
•3.Well Use(check well use): • ft. ft. in.
•
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. .ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. '
• Industrial/Commercial DResidential Water Supply(shared) .
`18."GROUT "
Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: ) ft. g ft- 'ate v- { . � p
Monitoring 0Recovery l`,,,J1� ft, 70 ft' )00-1,�1_ Gjt p`` �C$
Injection Well: ft. ft. Y1 itJ i�
Aquifer Recharge 0Groundwater Remediation •
q9:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.•
'
Experimental Technology E3Subsidence Control ft. ft.
.
Geothermal(Closed Loop) OTracer :20.DRILLING LOG(attach additional sheets if necessary) `-.- ..
FROM TO DESCRIPTION(color,hardness,soil/rock type,Brain size,etc.)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) fL ] ,l, ft. �� /
( ,b It
4.Date WeIl(s).Completed: Z.�—� Well ID# / •daft. ra ft. e3 rt7�:u�1 I-� .
a.Well Loc tion: ` /^1 ft. ft.
•
�� l� ft. ft.
• Facility/Owner Na1ne Facility IN(if applicable) ft' ft' -':' :i ( ,t �!R c-^!I
- . 755 :,1,8oictirtl 'Lane: , iilorfiA ft. ft. .. '
Physicrl Address, ity.and Zip / ft.' ft. JUL �� /_0Z�
�'� d�l� ,11'Z e� (� �� 21:'REMARKS: y
' County . Parcel Identification No.(PIN) ht.-' il/??IZs'� _
' Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
,(if well field,one lat/long is sufficient) 22,Certification: '
• 3t11,0 59 504/ N Api t / . , '/ 70 W zzz_e_____ 3-��' I
6.Is(are)the well(s) ermanent or : Temporary Signature fCertified Well Contractor Date
Hy signing this.form./hereby certify that the smell(s)was(were)constructed in accordance
7.is this a repair to an existing well: DYes or Ergr with I5A NCAC 02C'.0100 or/5A NC'AC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the cope glans record has been provided.to the well owner.
.repair under/21 remarks section or on the hack 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
f
9.Total well depth below land surface:- , AL) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3@200//'and 2 tr./00') construction to the following:
,16-'. 10.Static water level below top of casing: c (ft.) - Division of Water Resources,Information Processing Unit, •
•If water level iv above casing tcse"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
•
•11.Borehole diameter:' (-0 - (in.) " •q 24b.For Infection Wells: In addition to sending the form to the address in 24a •
/ ► ®h L,t�c j above,also submit one copy of;this form within 30 days of'completion of well
• 12.Well construction method: $-1 pi) 1"i /9 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: )v 24c. For Water Supply& Inflection Wells: In addition to sending the.form to • -
•
/ 1 . the address(es)-above, also submit-one copy of this form within 30 days of,
13b.Disinfection type: HT"' Amount: lA C Ui' completion of well construction to the county health-department of the county ..'
• where constructed. , I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016