GW1--03930_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GNU-1 For Internal Use Only:
1.Well Contractor Information:
1
S..
i; FROM TO DESCRIPTION
Well Contractor Name i 7 F fc NO ft
ft. ft.
NC Wci1 Contractor Certification Number ,.�j.rp[STE#is GASfG farmulh rased vseIfs aiL.L7 DER.if iicabte .... .:>
Miller Well Drilling FROM TO DIAMETER THrcx?,SS ntATFR1.4p1.
1..) ft. `00ft �j 1O j!F :_5V t
Company Name y Efis l!N—R --ASfiR`G't'ii?t TGSING eurhel:iaaF ctosei�lboa)..
2.Well Construction Permit#• 0414 FROM to n1Amx.l KK I'HICKNSSS MAThRIAL
List all applicable wall construction penniis.(i.e.UIG County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
WaterSupply Well: S.CRE N...:..............................................:..::::::::::: :::::.::::::::::•..,:::.::::::.:.
FROM TO DIAMETER I SLOT SIZE I TFnC&NESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) 211residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) RDBI :I
❑irrigation ❑Wells>100,000GPD FRONT I TO NIATF.RIAL EMPLACEMENT METHOD SAMOUNT
Non-Water Supply Well: tt• 7 fr•
❑Monitoring ❑Recovery ft. ft.
Injection Well: 12.t1 I1z 1,•t/i zL d
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL Eb1PLACENIENT METHOD
❑.Aquifer Test ❑Stonnw•ater Drainage
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer :30<E1R1rINGZCEG'.{ait3cbaddi3lonalseisfneassarv';>r>::;:
[ROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geotherma](Heating/Cooling Return) ❑Other(explain under:r21 Remarks) n
V ft. ft. s q °✓
4.Date Weil(s)Completed: Well ID# �1, � ft. J ft, � - -
5a.Well Location: Ito 0 ft. So .,I, ¢�i I
ft. ft.
FuIl!� f ,",)dine 11,112
Facilit
(y/Owner Name 7r/t— Facility IDq#(ifapplicablee) ft. ft.
1,315 �.1�O rls2 1 `�
Physical Address,City,and Zip —�— ft. ft.
P,F1�{r'ZRI�
County parcel Identification No.(PIN)
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(it'wcll field one latflong is sufficient) 22.C,egr' catid10
6.ls(are)the well(s): C191manent or ❑Temporary Si,na[ure of Certifizd Well Cant actor Date
gv sr,•,ming this 1brm,I herehi'rertlij-thur the rll(x1 wvud'(1vere)c•onstruvic/in ac•cot'dtrne'c with
7.Is this a repair to an existing well: ❑Yes or 8No i5A NCAC 03C.A100 or IiA NCAC 03C.0300 Well Consintc•lian Standards and thal a cnpi•
ifthis is a repair,fill out kiogn"11 consimcdon iulfnnnatinn and explain the rature ol'the of this record has been provided to the urll owner.
repair under 9Z1 remarks section or on the back 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 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:
�� (1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all deptla if different(example-3(ai300'and 2(,1 ri0� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10 t lft) 24a. For All Wells: Original form to Division of Water Resources (DWR)•
(fwaler level is above casing,use"+' ]nlonnation Processing*Unit,1617 MSC.Raleigh.NC 27699-1617
11.Borehole diameter: (in.) 24b.For injection Wells:Copy to DWR,Underground Injection Control(iUC)
f Program,1636 MSC,Raleigh,NC 2 7699-163 6
E2.Well construction method: !lrY 1r,e`':� 24c.For aT+tater SuDniv and ODen-1 o0o Geothermal Return Wells:Copy to the
(i.e.auger.rotary.cable,direct push,etc.) county environmental health department or time county'where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPID Copy to DWR,CCPCUA
13a.Yield(;pm) Method of test• � Permit Program,1611 MSC,Raleigh,NC 27699-1 611
13b.Disinfection type: Y Amount: 0 U ,l✓
Form G W-1 Noah Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S