GW1--03193_Well Construction - GW1_20240524

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WELL CONSTRUCTION RECORD(GW-1) Fur internal Use Only:
1.Well Contractor Information:
Pt.rr y A e e C e i 14.WATER ZONES
FROM TO DESCRIrTIO'
Well Contractor Name Z6Sft. -70 ft. Llear
1.'1 G3 ft. R.
NC Well Contractor Certification Number 15.OLTER CASING(for moltf.cased wells)OR LINER(If ap icable)
MILLER WELL DRILLING FROM ft. TO DIA.\IETt•:R in. THICKNESS NIATERIAI.
j07 ft. R/� a l E8 S to e
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DI4\IETER THICKNESS M.TERIAI.
2.Well Construction Permit#: ft ft• in.
List all applicable p•ell construction permits(i.e.UIC.County.Slate.f arianee.etc.)
ft. ft. in.
3.Well Use(check well use): -
17.SCREEN
Water Supply Well: FROM U) UTA?IETER SLOT SIZE THICKNESS SIA'IERIAL
❑Agricultural GMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) 2'l(esidential Water Supply(single I ft. ft. in. '
❑Industrial Commercial °Residential Water Supply(shared) Ia.GROUT
❑irrigation °Wells`100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD.4 A\3OL'T
Non-Water Supply Well: O ft. ft. portlanl P Ohre d
❑Monitoring -Recovery tt. R.
Injection Well: ft. R.
❑Aquifer Recharge :Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery Salinity Barrier FROM To \1ATERIAt. EMPLACEMENT METHOD
=Stonnwatct Drainage R• ft.
OAquifcr Test l:
❑Experimental Technology _Subsidence Control rt. rt.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessar})
FROM TO ! DESCRIPTION(color.hardness.'mil/rock npe.grain size.ets.l
OGeothermal(Heating/Cooling Return) °Other(explain under(21 Remarks) rt. ft.
[1)J)i Well ID# R. ft.
1
4.Date Well(s)Completed: M
ft. ft. [ i .,t...i,>„ 1- L.,
5a.Well Location: -
CJ14r!e5 �cactirnun rt. fr. 2624
ft. ft. MAY 2
Facility/Owner.Owner Name Faeili:y iD*Iifapplicable) .
111I AnnS ' I n Rgye5viile �010"l
r ft. ft. f.::Y �..,�J � '`fi t[
ft. ft. i'f .naGV• �
Physical Address,City',and Zip -
C 1`(j 21.REMARKS
County Parcel identification No.IPiN I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld,one lat/Icug is sufficient; 22.Certification:
6.Is(are)the isell(s): i ermanent or OTemporary Sia)at.trcofCertilied\\'cilC'ur.[raetur Dec
t/ Rr signing this I/ni..I hereby co Iilr that the el/tct was v ere)constructed ucted in accordance wrin
7.Is this a repair to an existing well: ❑Yes or o 15.t NC-IC oX'.tiffJO or 15.4 VC'A('02( 020:1 Well Construction Stundards and lion is(opt.
If this is a repair.fill out blown well construction information and explain the nature of the of this record lies teen provided to the well owner.
repair under ii2I remarks•section or on the Lack of this fn1 m' 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well construction info
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft.) Submit this GW-1 within 30 days of well completion per the following: -
For multiply Kvlls list all depth.,ifJifferent(example-3(42 tor'and 22( lat1')
24a. For All Wells: Original form to Division of Water Resot.rces (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit.1617 MSC.Raleigh.NC 27699-161'
11.Borehole diameter: (in.t 24b.For Infection Wells:Copy to DWR.Underground Injection Control(LUC)
,Q Program.1636 MSC.Raleigh.NC 27699-1636
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12.Well construction method: ` I r h0 a~ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary.cable.direct push.cnc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:13a.Yield(Rpm) 2-C�+ )7 y. 24d.For Water Wells producing over 100.000 GPD:Copy to DWR.CCPc'1:.4
Permit Program. 161 1 MSC.Raleigh.NC 27699-16 i 1
••' Method of test:
13b.Disinfection type: { l s t}• Amount: Vt�
1 Cu? , T
Form GW-1 North Carolina Departmeni of Environmental Quality-Division of Water Resources Revised 6-6_01S