GW1--03971_Well Construction - GW1_20230612

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: . ,
1.Well Contractor Information: f
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l l7 es ail;r 0_r-! g . i l
>9 ; a_ a irzolb a :.: :,:
Well Contractor ame FROM TO DESCRIPTION I
7 9 fr. 90 ft.
- Li 3 3,5 j I13&. ft. 11 --ft.
• NC Well Contractor Certification Number
»OLITER.CASiNG ffar trtnln caseei:WilLS1:c7R.r:INER:tf appfreati10 : ,: :..::.:i
Miller Well Drilling - FROM �TJO DIAMETER THICKNESS �lttA,TERIAL 9
Company Name ft rl2^ ft- tn. s5� ,/ /o ClIc �, Y� /
La I
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469NN1 R:£r4SI1RC`Q3Tc 15;671V :f eothezinzfcloseu*ap) :':>. 1
2.Well Construction Permit I FROM ro DIAMETER THICKNESS NI AT ERIAl. I 1• List all applicable well construction pennits(i.e.UIC County,Stale.Variance,eta) • Ct. ft. in.
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3.Well Use(check well use): ft. fi in.
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:1:r;.SCREEW
Water Supply Well: PRU11i TO DIAMETER SLOT SIZE TAIGKNess MATERIAL
' ❑Agricultural ❑MM�unicipal/Public ft. ft. ,in.
❑Geothermal(Heating/Cooling Supply) EfResrdentiai Water Supply(single) ft ft in.
• ❑industrial/Commercial ❑Residential Water Supply(shared) TGRfDfllT
❑irrigation ❑Wells>100,000 GAD • FROM TO MATERIAL 1 EMPLACEMENT MFTFIOD S AMOUNT
Non-Water Supply Well: t'.) ft. '' , ft. 1c Y,i-,htf'._A Y'oJW117Cc
f r�_ I
f' / /
❑Monitoring ❑Recovery ft. ) ft.
Injection Well: �t// 7_Y1�cY1,1 C' .Yr9 JAL!`r
ft. ft. 1
❑Aquifer Recharge ❑Groundwater Remediation •
19 SA?t /G A'IiEL.PACK:(rtaaalcesb1e3 il ,... : ; l
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ' TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer
- _O::DRiIrI:Il�]:v^L43u'.fattacli ilAitiunaisl;eet:it'n'ecessarH) .: : .:�
(Heating/Cooling ( p "�1 Remarks} FROSt TO DESCRIPTION(color.hardness.soil/rock tvau crams size.etc.!❑GeothermalReturn) ❑Other(explain under rr_ 0
it. /j ft.
�/yy
4.Date Well(s)Completed: f-7 -2 2 W'eIl HID# ft. fr. ., ..
Sa. eIl Location: . ft. ft. t t...<.”.A r Ni. lt.� .
r�i+riG'l. S ii1 JUN 1
ft. ft. ; ! 2023
Facility/Owner NameIt. ft.Facility (if applicable)
//t-r Cell • ft.. ft. 1'flitiifirr4:t4:11.Pr.,,,...:: g ..i.e.1
DWOISOG
• Physical Address,City,aid Zip .
.::2i REMARhuS ;. -
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Cer'"cation
5c 32 : i N LU( 3 77fo ' (YS W -1 ( t
• 6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certifie 4Vel(Contractor' Date
By signin,ti this./arm,I herenr rerrift'that the well(s'i was Ewer•:•)cvnstrzu',ol in accordance with
' 7.Is this a repair to an existing well: ❑`Les or E'+tvo 154.NCAC 02C.0/O0 or Li-I NCAC 012C.0200 Well Construction Standards and that a cape
If this Ls a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 02l 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 1 0'W-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional page's if necessary.
drilled:
! f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I (ft)
For mulnple wells list all depths if different(example-3(a3200'and 2(5l o0')- Submit this Gbri•'-1 within 30 days of well completion per the following:
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10.Static water level below top of casing:
( (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR). •
If water revel is above casing use"+" information Processing Unit,1617 MSC•Raleigh.NC 27699-1617
11.Borehole diameter: (9 (in-) 24b.For injection Wells: Copy:to DWR,Underground Injection Control(MC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary'.cable,direct push,etc.) 1 / 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
- FOR WATER SUPPLY WELLS ONLY: .
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gprat) ' ( ��! Method of test: I14,I.✓ •Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: H J L/ Amount: VLF (4p ; 1 -
Form OW-1. North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6‘201 8