GW1-2021-01514_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
yj/N] p z`p 14.WATER ZONES - - -
Well Contractor 4amc FROM TO DESCRIPTION
,v ft. •� ft.
1-4 0-3 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a livable
Miller Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
ft- /� �
ft. P in. S)' 2 C
Company Name !//6
ry��f i 16.iNNER CASING OR TUBING geothermal closed-loo
2.Well Construction Permit#: LI�.C.o2 `1�u.�y FROM TO DIAMETER THICKNESS I MATERIAL
List all appliccble Nell conctritction permits(i.e.1/1C.County,.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft, ft, in.
Geothermal(HcatinglCooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial n Residential Water Supply(shared) 18.GROUT
1m.9-ation FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
ts' u
Monitoring DRecovery fu G ft. �.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test rJStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRiLLiNG`LOG attach additionalsheetsifnecessa"
Geothermal(Heating/Cooling Return) 00ther(explain under#21 RemarksLi
FROM I TO11,, DESCRIPTION color,hardness,soittrock ,grain size,etc.)
/ 0 ft. �`� ft. Ci
4.Date Well(s)Completed: Well iD# 12o fa ft-
55aa.Well Location: ft. ft.
`�
C4)�L `l QY 1 .S ft ft.
� I RECEIVED
Facility/Owner ai a Facility ID# if applicable) ft. ft.
i;29 �c Cs� C.'e'e- bra' ft. ft. MAN X 9
Ph ical Address.Ci ,and Zip
fL ft.
cessfilyunif
Ph
y51cYm16(n311m z1.REMARKS ec Ion
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one]at/long is sufficient) 22.Certification:
3�v60, 77 g� N GPI° 61 -7ZlO W
_Z--VA-Z1
6.Is(are)the well(s) ermanent or OTemporary Signature of Vertified Well Contractor Date
Nv signing this fain, 1 herehv cerii[v that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes "or 12< with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standordr and that a
If this is a repair,fill out known well construction information and explain the nature Qf the copy of this record has been provided to the n'ell owner.
repair under..21 reniarkr 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 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:t (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list a//depths if different(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: SO (ft.) Division of Water Resources,Information Processing Unit,
1fmvier/evel it aho•e casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: to (in.1 24b.For Iniection 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: 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
c,
13a.Yield(gpm) Method of test: Al/ 24c. For Water SUDDIV&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �� completion of well construction to the county health department of the county
where constructed.
Font G W-1 North Carolina Departgrent of Environmental Quality-Division of Water Resources Revised 2-22-2016