GW1--03972_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD QW--1) For Internal Use Only:
1.Well Contractor Information:
Rre11 Coniraoi6r
7��5Name FROM TO DESCRIPTION
j,. fr. �y� fr. '
2 tISYJ 01A
NC Well Contractor Certification Number
• .:1a>1JliT'Ef ��iS,.:+iG farmultifiaseilrells>OEtt$i+iElLif ,:iiciibte...:.... ..... :...
Miller Well drilling FROM TO DTALf$TF"R THICKNESS MATERIAL,
ft. ft. in.
Company Name r1 r� {6;:IIiNER;CdS3i?G:OR1 UCi1\Li.f eotheiia3ciasetI=.lbu
2.Well Construction Permit#• tr :P— e'ROI11 1 TO nIAM !FR IHICKNFSS MA7F IALry
List all applicable well constriction permits(Le.UIG County,State,Variance,etc..) i ft. g' ft, I in.
3.Well Use(check well use): fe. ft. in.
Water Supply Well:
FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public fr. ft. in.
❑Geothermal(Heating/Cooling Supply) tMResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 7.
Ili cm F:: .... ,
_.
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATF-RTAL FAIPLACt'NIF.N7 NrF.THOD S ANFOUi,i
Non-Water Supply`.Nell: a ft. ^� ft. v lA% rrxCJ
❑Monitoring ❑Recovery ft. U ft. Cat i,L3�1t
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19 sSi6NT31IFPAC�£.E f.2iis#ible3...> X.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MXTERLAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
r
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ?i36'Di2111N:G`IC :E3ficli'addifiau3Esliebts:€arceFsah
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I To DESCRIPTION(Color,hardness,soillrmk type.Brain size,etc.)
ft. s ft. l A o- t t .�
4.Date Well(s)Completed:CL� Well ID#
ft. ft. t;...P.r-i�' !
Sa.Well Location: �
ian
�� i d!!i9!a Lj G ft. ft.
Facility/OwncrName ft Facility lD (ifapplicable) ft. frJUITI 2 2023
Crus,n I/J ­�0— r_9W,,jnw&_V
Physical Address,City,and Zip ft. ft. D%VQi30G
County Parcel Identification\o.(PIN)
5b.Latitude and longitude in de.-ees/minutes/Secands or decimal degrees:
(if well field,one laviong is sufficient)
M22. e 'rc2' �
6.
Signature of Certified Well Contractor Is(are)the weIl(s): ermanent or ❑'Eeinporary Dar.:
� Q,si•ning this J,-nr,i here by vej. jj.that the wr11(al wa,-/were)vanatnu•rad in accordance uilh
7.Is this a repair to an existing well: --Oyes* 2 or NO - 15A NCAC 03C A100 nr-1 S•-I NCAC 01C.0300 V ell Conatn:ctiar.Standards and that c cars
ifthis Is a repair,fill ota known well constriction igfbnnation and explain the nontrc of thc. ofthis record has hcen provided to the well owner.
repair under 921 remarks section or on the back oJthis•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 constriction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells -(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL n'STRUCTIONS
9.Total well depth below land surface: �' A't (ft.)
For multiple wells list all depths if different(example-3@)200"tin d 2 ft100') auuuuu this GW-1 within 30 days of well completion per the following:
n`�r 24a. For All Wells: Original form to Division of Water Resources (DWR
10.Static water level below top of casing: .^� M-) information Processin* )'if water level is above casinr,,,use"+^ �Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DWR.Underground brjection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-163 6
12:Well construction method:Ana M(i.e.auger,rotary,cable,direct push,ac.) 24c.For Water Suonly and ODen-Loon Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Well Droducina over 100.000 GPD•Copy to•DWR,CCPCUA
13a.Yield(-,pm)m) r_Q Method of test: N
nn Permit Program,1611 MSC,Raleigh, C 27699-161 1
_L-Pi
13b.Disinfection type: i Amount:
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Res'ou Ices
Revised 6-6-201 R
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