GW1--03961_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
e " '�--�t�(-?Ft��e✓ � L '✓ ,�i�}I?� 14.WATER ZONES
Well Contractor Name lJ FROM TO I
/DFSCRIPTION
' ft &fft
ft ft.
NC Well Contractor Certificationlumber 15.OUTER CASING(for multi-cased wells OR LINER(if a lic:ible)
MILLER WELL DRILLING FROM - To DIAMETER THiRr".'ESS 11., 161.11,
Company Name ft. ft (ice in. "o k2j 1'�✓�.
16.INNER CASING OR TLUBLNG(„eothermal closed-loop)
2.Well Construction Permit:: I 19 2 2- P FROM 1 To DLaMETER THICKNESS MATERIAL
List all applicable it-ell construction permits(i.e.tilt,County.State,l7aiance,etc.) ft• it. in. I
3.Well Use(check well use): ft. it. in.
Water Supply Well; 17.SCREEN
FROM I TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) GR512ential Water Supply(single) it. ft- in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROtt TO hL4TERIAL EMPLACMIENT NIETHOD&AMOGNT
Non-Water Supply Well; (1, ft. f,- n 1, P f tr,S7
❑\.fonitoring ❑Recovery 7 ft. r ft
Injection Well: •7 20 �� �1�it3n s
ft, ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
'
❑Aquifer Storage and Recovery ❑Salinity Bairier FROM I TO T kL%TERI:\L E&IPLACE\IENT METHOD
❑Aquifer Test- ❑Stotmwater-Drainage _ ft. ft.
❑Experimental Technology ❑Subsidence Control ---- ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO DESCRIPTION(color,hardness,soil/rack type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under =21 Remarks)
tt / � ft. ft �,la S i ti_� q YCtve.
4.Date Well(s)Completed: Well ID9 -7c tt �7Y .� >T,✓
5a.Well Location: ft. ft.
L_ i V ro...Li
Facili y!Own Tame Facility ID.'-.(if applicable) ft. ft t ,
i) i 1G71�.•._S i-io jii'�-i''1 1 t7� �� .
Physical Addres,City,and Zip lJ ft. ft.
21.RE VL+,Rli&
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one latflong is sufficient) 22.Certification• n
6.Is(are)the well(s): Op'rmanent or ❑Temporary Signature ofCenit+ed lWRC.onfictor Date
Rv sig»ing utisjo;mt,l he;zby certifi that the t+a11(s):cgs(rrere)consnucted is acconlmtce uitr5
7.Is this a repair to an existing well: Yes or a i`o 1.5.4\CAC 02C.0100 or 1=.4\C.4C 02C.0200!Yell Constn;ction Standards and that a cops,
If tltis is a repair,fill out b7ou-t well constriction it formation and d explain the nature of the of this recrirdi has been provided to the irell oinner.
repair tinder"21 remarks section or on the back o(this form.
23.Site diagram or additional well details:
S.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if netiessary.
drilled: 24.SUB'MITTALINSTRUCTIONS
9.Total well depth below land surface: ��� (ft.) Submit this GW-1 within 30 da s ofwc0 completion er the following
For multiple wells list all depths ifdierent(example-3@300'and 2@1000 y P P b.
f 24a. For All `Yells: Original form to Division of Water Resources(DXYR),
1J Static wafer level below top of casing: bey (! (ft.) Information Processing Unit,1617 MSC,Raleigh,INC 27699-1617
Iflvaterlevelisabore casing,use"+r"
11.Borehole diameter: lG (in. 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
�j Program,16361MSC,Raleigh.NC 27699-1636
12.Well construction method: I w��I 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY R ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611\4SC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type* V� Amount: a)j
Form GW-1 North Carolina Department of Environmental Quality-Division of lNater Resources,
esour es Revised 6.6-201 R