GW1--03986_Well Construction - GW1_20230612

SWELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only: i
1.Well gontractor,Information: .
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{o!1 h�1f7My.rU ' II. I .� � >±I 0 S .sE:rti,-T-r-RZON--
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FROM TO I DESCRIPTION '
Well
�C-foJntractorAUe 9s,
ft. 60 ft• j v:'
NC Wcll Contractor Certification Numbcr
x:EDOT£?.E:AS'f3G 1fc::aui5t.:ase3'Se1u:fl�2I:ll��t2't�.at;t3Tarabte. .. i
Miller Well Drilling FROM I TO I DrAMFTER I TIUCKNESS MATERIAL.
/> C. Ft'3 ft. / in.
Company Name SvI SINNER:
UU rNC OR it1C3Il>ICJ:,,eeother:aaf losed loon;
2.Well Construction Permit#: 21 FROM •ro ninmr:i 11:R t yacKti MATERIAL
l+.RIAt.
List all applicable i ell consimcdon pennits(!.e.UIC,County,State.Variance•etc.) ft. ft. I in.
I
3.Well Use(check well use): €t. f in.
;•
Water Supply Well: FROM TO DUNIETER I SLOTSTZE I TATCKh"SSS I VIATRRTAL
❑Agricultural ❑M�unicipal/Public ft. I ft, in.
❑Geothermal(HeadngiCooling Supply) Oe. ential Water Supply(single) ft ft in'.
❑Industrial/Commercial El Residential Water Supply(sliared) - -
i%C12d3?iT
❑Irritation OI.VelIs>100,000 CHID FROM TO MATERIAL I r•.NLPLAC&MENT METHODS AhrOUN'T
Non-Water Supply Well: O tt. -2 ft-
! 11i ?i y1
❑Monitoring ❑Recovery ft. 'C� ft. I/ )n`"c I `
Injection Well:
OAq-uifer Recharge OGroundwater Remediation ft ft.
I9.:5 N rl tP.«lam Pt3: S'i,airs?apt3ter::;'.
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EAIPLACEN NT AIE"ruop
❑Aquifer Test ❑StontawaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control 8. fr._
OC,eothermal(Closed Loop) ❑Tracer 2>l::�Jf2c¢.•�hi:�,.L.^.�.t�t_c§<aaeiiioi> isT_�e;ts d'nec�snt-v).. ..::::.. ..: :::. ,.;..,
Roto:,
OGrothermal(Heating/Cooling Return) ❑Other•(explain under#2I Remarks) FROM TO DESCRIPTION h::riness,soiurock type.acsin size,ete.t_ f t
+ %V O
4.Date Well(s)Completed: Well IDS � I
ft.
5a.Well Location: ft. i
()I� ft. ft. _�
Facili /Owner Namc Facility 1D�(if applicable) ft. ft.
1 r22 I uS y► kp_" i)1 ft. f. N 2 Lid i
Phy ical Address,City,and Zip C I ft
R I 7
County Parcel Identification No.(P;N)
i
Sb.Latitude and Iongitude in de.grees/minutes/secunds or decimal degrees:
(ifwcll field,One lat/Ioag is sufficient) 22.Cer tit catien• / �?
Co Z 7-Z Z_
6.1-s(are)the wali(s): Epermtanent or Cl T emporary Sigra( Oi ettifed�vel::ont.a�tor Date
�qv sr,tin,{thisai)rm,l herehr ret•t!fj'that the xril(s)tvas live r••j;vns7ra•tc</ir.ar.%a•d rnre With
7.Is this a repair to an e;dsting well: ❑yes ttr O l:A NCAC 02C.0100 nr 15.4 NCAC 02C.0200 Mell Conatn:crion Standards and that a cnpr
ifthts it a repa!r,)il!Dirt knows cell construction Itjnnnatiat and explain the rotttre ofthc ofihis record has hcen provided to the atoll of ner.
repair carder m2!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 constriction info
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:
24.SUBMYTT_,•AL.INSTRUCTIONS
9.Total well depth'below land surface:
For multiple ivells list all depths if d fjereni(example-362000'and 2(a'1 rfi'j ( ) Submit this GbW-I within 30 days of well completion per the following:
10.Static water level below top of casi ng: 1 , C,:) 24a. For All `TJeRs: Original form to Division of Water Resources (DWR)•
/f'uater level i.r above casing,use"(+ intortaation Processing Unit,L6I7 MSC,Raleigh.NC 27699-1617
II.'Borehole diameter 1 (Iu,) 24b.For Injection'Wells:Copy,to D-%VR,underground injection Control(TUC)
Program,1636 MSC,"Raleigh,!NC 27699-1636
12.Well construction cable,
method: L' f( 24c.For Water Suorlly and Open-I.©on Geothermal Return L,�
(i.e.atiger.rotary,cable,direct pt:sh,etc.) dde136•Copy to[:.,,
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPID:Copv to DWR,CCPCUA
I3a.Yield m .(/ (V Permit Frogmen,1611 MSC,KalCIgh,NBC 27699-161 I
(ep ) Method of test:
13b.Disinfection type: Amount: 1A C,lJ'
l
Form OW-1 North Carolina Department of Erivironmental Quality-Division of Water Reso—1 es Revised 6-6-2018