GW1--03960_Well Construction - GW1_20230612

WELL CONSTRUCTION R JRD (GW-1) For Intemal use+`_.j �
➢.Well Contractor lnfoi'mation:
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Well Contractor Name FROM TO I DESCRIPTION
L
NC Well Contractor Certification Number f�>:fltlTEttCastkC-:'fdrai�ttre2sedare:Is PJtt.cllv���f. tizable
Miller Well Drilling FROM TO DIAMF•TF.R THICKNESS 'MATERIAL
Company Name ft 1 ft in.
Cr 1
`' f5r9.ytu£R :�ol?+G:Dk c LIsING>f eothe.�rizf closed,loo ) ;'':
2.Well Construction Permit V�O I Z FROM TO DIAM@ I r.R 1 HICXNFSS I MATERIAL
A RIAL
List all applicable uxill consirue ion permits(Le.UIC,County,State,Variance:etc..) fc. ft. in. i
3.Well Use(check well us6): ft. ft. in.
'.v:'i `:isi::%.i,::.:i'f.:4::i::i::;.:i::v:':.:::::�:'i1 ii+�i:::: ::
Water Supply Well: FROM TO DIAmPTER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. ;.in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. ( in. i
01ndustriaUCommerciai ❑Residential Water Supply(shared) -
❑Irrigation ❑Wells>100.000 GPD FROM TO MATERIAL RNIPfACENIRNTMr. O7 A\iOL'e
Non-Water Supply Well: 0 .�'j:'S�rA /
❑Monitoring ❑Recovery ft. °t. r B tt ,, 1
Injection Well: '�' i _
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.>3J::SA•1�slGIfi4�:F.II.gh:CB�{d'«b'1ccaDle>.,.; ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FAU111t TO IDIATERIAL I EMPLACEMENT METHOD.
❑Aquifer Test ❑Stormwater Drainage • ft. ft.
❑Experimental Technology ❑Subsidence Control fc. fc.
❑Geothermal(Closed Loop) ❑Tracer �ll.II2RFiIISa�rGEzft�s dei>otz_z�teeti[ffneciv
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 21 Remarks) FROM to DFSCRIPTIO\(ccln,In dncss sorUroch tYpe.-ram size,etc.l
ft. fr.
4.Date Well(i)Completed: �!q In Well➢D L' fc.. fr._
So.Well Location:
.i, 7 es a e'r i ft. ft.. t r�� :l t n ~Za .%—e. ;
Facility/Owner Name Facility lD;#(ifapplicable) fS ft. I ,
0 9 2023I
Physical Address,City,and Zip ft. ft. 1n(+:Vr-;W-,_1 ; f:. e' U111 .
1 err,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in deg ees/m nt:tes/seconds or decimal dee ees: j
0fwc1l field,one lavlon_is sufficient) 22.Ce ration
is 41111t ® .
6. Signature of: iced�t-etrContracmr ✓
iis(are)the weIl(s): tH�zrmaneat or ❑'=enaporary.. Date
dv sigrin,;this brat,11.•vrehr ve;;ill•[hut thr ae1!{s)..vus lwere);uns.nu t d i^ere+rd tr,a t^i:F.
7,is this a repair to an•zzisting vieli: Dyes 'or &1111 15.E N01C 02C.0100 nr 1S:)NC4C"02C.0200 W eli Constntcsiar.Standm•ds and that a mpg•
i/tltis Lc a rcpain fill oat known well consiniedon h jatmatia:and acplain the nature ofthe of this record has hcen provided zo the;veil of rcr.
repair under 921.remarks section or on the back of this,form.
23.Site diagram or additional well details;
8.For Geoprobe/DPT ov Closed-hoop Geothermal Wells having the same You may use dee bacic of this page to provide additional well construction-info
construction,only 1 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.SUBM1TTA 1rrSTRUC'➢IONS
9.Total well depth below land surface: a2( 'J
(fL)
(For multiply wells lis:all drptltc if different(example-3(a 200'and 2(V 00') Subttlne this GOw'-1 within 30 days of well completion per the ffollowing:
10.Static water level below top o:casim Z4a. For AH Wells: Original.) (gam) ginal form to Division of Water Resources {pt.VR),
ifwaterlevel is above casmg,uve"+" lnlormation Frocessing Unit,1617 MSC.Raleigh.NC 27699-1617
11.Borehole diameter: (in.) 24b,For Infection Wells: Cbpy to DWR,Underground injection Control(TUC.)
Program,1636-MSC,Raleigli;NC 27699-1636
12.Well construction method: .) r _ 4
(i.e.auger,rotary.cable,direct push,etc.) —`-"t 24c.For Water Sunnly-:"i Oaeir-Loaf)d -otherm2l Return Wells:Copy to the
county environmental health deoa;rtmenr of the county where installed
FOR WATER STIFFLY TELLS ONLY: 24d.For Water Wells pro due ing over 100,000 GPD•Copy to DWR,CCPCUA
13z.Yield(,-pm) Method of test: Permit Program,1611 MSC,Ralcigh,NIC 27699-161 1
13b.Disinfection type: • 4 a Amount: �ZI (Lf t7
Form GW-1 North Carolina Department of Em'ironmental Quality-Division of Water Resourcels
Revised 6-6-:0I8