GW1-2021-01695_Well Construction - GW1_20210323

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WELL CONSTRUCTION R_ _ORL :W-1) For Internal Use,
1.W"ell ontra" n cttor I/f�olrmation:
Q1- ' eece- 14.WATERZONES
/ J FROM TO DFSCRIPI'IOF
Well Contractor Name
a rL
NC Well Contractor('cm fication\umber 15.OUTER CASING formsdtieaed wd13)OR LINER Ba hle
Miller Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
r � a In.
Company Name 7 /
�q _ !Q 16.INNERCASING ORTUBINC dasW-bo
2.Well Construction Permit th 19 FROM TO DIAMETER THICKNESS MATERIAL
l.r,t ull upplicnhle will um.mmuon prrmux/�e. 1/1(',C n,nn.S1.1e. Vanuna•,er<'l 2 ft. I in
3.Well Use(check well use): F, ft in.
17.SCREEN
Water Supply Well: FROM I TO DAMETER SIAT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public
Geothermal(Heating/Cooling Supply) ®Residential Water Supply lsingle) D h is
Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
Iitipation FROM TO MATERIAL I EMPLACEMENT Vu7rHOD&AMOtNT
lion-Water Supply Well: fL ft.
Monitoring 13izecovery fL a
Injection Well:
M1 R.
Aquifer Recharge QGroundwater Remediation
19.SANDIGRAVEL PACK
Aquifer Storage and Recovery Salinity Barrier mom TO MATERIAL EMPLACEMEWMEFHOD
Aquifer Test ❑Stormwater Drainage ft ft•
Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG butticla additional same,iflumessa
Geothermal(Heatin Coolin Return) nOther(exlain under#21 Remarks) FROM TO DFsemPrron romp n.rdner.,rommckt be.tn,
�fL J8d FL Gran, e
4.Dale Wellls)Completed: Well ID# fL fL
5a.Well ocafiono D. fL
h w
SVle neap rL "Facility/Owner Name Facility lDh(ifapplicable) ft R' MAR
A -7 Ntg.f ll;efi -;ue llewej /!e `L `L r.
Physical Address,Ciry.and Zip fL ft.
SQ
//4` v 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r B o`Al O -'
(ifwell field,one latlmi,is sufficient) / 22.Certification:
25 : 62, 157 u N 0 ?-y 0 yr bZ � W
6.Is(are)the well(s)SRrminent or OTemporary Signature Well Contactor Date
a�.�i/_ Ny eigning,hi.v/orm. I he,bi nrrili d a,do,wet/(r/vnv(vrrc/r.o,1 ,ed in o,,ora m,e
7.Is this a repair to an existing well: Was or QNo with ISA N('A( 02('.UI tut or ISA A'('A('02(',02W Well('onaauction Siarulards and rhos a
IIftha iv a repair fill out known well ronrnuction inform um oral erphcm the nature of the cwpr ofib,,rcmn/har Min pmr,ded to tM well owner
repairwider Blmmmiss limoronihehockpf,hi..fr+rm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Cloxd-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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled'
7p SUBMITTAL INSTRI'CTIONS
9.Total well depth below land surface: J 0 (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
l'or.... lr well,lrs,III csvp1h,,fdp•nan(ammp/e-3@200'an120100')
construction to the follawmg.
10.Static water level below lop of casing: 7� (ft.) Division of Water Resources,Information Processing Unit,
lI varer h,el,.shore ro,wg.u.e - " 1617?Tail Service Center,Raleigh,NC 27699-1617
11.Boeebole diameter: (in.) 24b. For Iniection N ells: In addition to sending the form to the address in 24a
y1f? above, also submit one op) of this form within 30 days of completion of well
12.Wall construction method: J7 construction to the following.
I 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: mp,� 24c. For Water Supply& lit eetion 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: off(/- completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Emimnmemal Quality-Division of W ater Resocma Rm ised 2-22-2016