GW1--03984_Well Construction - GW1_20230612

VVELL CONSTRUCTION RECORD (GW-1) 1 For Internal Use Only:
1. Contractor Information-
Tan % C "d1 t�,t_ d"1 5 i4 T�'.biT3sRyt3N1'. ;
i t - - FROM To DESCRIPTION
Well Contractor Name �� y ft. J 1,°l rt• �,B I ram,
C 3,35 ft. ft.
NC 54'dl Contractor Certification Number DU It CASiNkC--(for.mis Iti-6i S­ka 4waiS>OR.E
Miller Well. Drilling FROM I TO I DIAMETER THrCRNFSS dIATERI.AL
/ ft l ft t in-
Company Name P V G
� . tlSEl.Vfis'Q31i'EUS]�;V.t l: fhe�-itiaE.fitosePl-ioo ;:':
2.Well Construction Permit#: t/f+�� _ t �V FROM 70 DIAMETER 'THICKNESS NIA1FR141
List all applicable Hill construction pennits(i.e.UIC,County,State,Variance,etc..) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :37iSs �F:::..::::::::::...:::::::.:.:. .... ::::.::.:..:: :::::::::::::._::::::•;;:;:•: ::>:;;;;>:
FROM[ I TO I DIAIIIETER I SLOT SIZE I THiCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/cooling Supply) eR sese idential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 3fiGAf3fi1F::
❑irrigation ❑Wei is>100,000 GPD FROM I TO MATERIAL RAIPLACF.MF.VT hrF..TFFOD S Anrou,
Non-Water Supply Well: ft. ft. -�
❑Monitoring []Recovery '1 t't.
c /v ft. f i 1,)+tC'v21�' ;jyt
Injection Well: J
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
ScsiY�iG1iA.E1.,
❑Aquifer Storagc and Recovery 13Salinity Barricr FRO51 TO NMSTERIAL EMPLACEMENT 31ETHOD
❑Aquifer Test ❑Stonmwater-Drainage
❑Experimental Technology ❑Subsidence Control
DGeothermal(ClosedLoop) ❑Tracer ;20z DRIi 111NG.LO G fattcH 5ildi4iieii3L'sfieets.tf,.ecessai
FROM TO DESCRIPTION(color,hardness,soil/rock ry e.gain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under R21 Remarks) p� /1 t
0 ft. Dt> fr. Clad + Lcv r/5
r
4.Date Well(s)Completed: Well ID# I�r, ft. d fr. a�Z
ft.
5a.Well Location: � ft. -
Facility/OwncrNName r Facility ID#(ifapplicable) f6 ft.
JUN 1 J
6�.� ✓h� �(t9 f�f�6!D r.l.�t
Physi I Address,City,and Zip — ft. ft.
�i23iR1VARt� ...:..... •. � ..
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certil cation
'
6.Is(are)the well(s): 2ermanent or ❑Temporary Signature of Certifed Well T ontr&for Date
'- gv si,ming this faint,1 hereh;.c,*rtiJp that the well(s)was(wen)constructt:•d in accordance kith
7.is this a repair to an e3isting well: ❑Yes or O 114 NCAC 0?C.0100 or li4 NCAC 02C.0200 Kell Construction Standards and that a cups
Ifthis is a repair,fill out kno)sn well constnuction infonnatinn and erplain the nature ofthe ofthis record has been provided to the sill mmer.
repair under 021 remarks section or on the back of ibis 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 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.SU13MITF'AL LN'STRUC.TION3
9.Total well depth below land surface: 70D (ft
For multiple wells list all depths ifdilferent(example-3@200'and2(g1001 ) Subunit this GW-1 within 30 days of well completion per the following:
7/ (gE� 24a• For All Wells: Original form 'to Division of Water'Resources (DIA R).fl@.Static cvater level below!op of casing:
if v,ater level is above casing,use"+$" - information Processing Unit,161,7 MSC Ralei?I1.NC 27699-1617
11.Borehole diameter: (ha.') 24b.For injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ((/ 61 3� I/� $mod 24c.For Water Sunnly and Open-Looti Geothermal Return Wells:Copy to rife.
(i.e.auger,rotary:cable;direct push,etc.) county environmental healtkilepamaent 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 m Permit Program,1611 MSC,Raleigh,NC 27699-161 1
(,gyp ) Method of test: g
13b.Disinfection type: Amount.,- 1/ il0
—m
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S