GW1--03987_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only;
1.Well Contractor Information:
' Malinle 19rjt- n_'r. _..,rs>>:asi>s:ii<:za.»:>::»:<::::>:>:<:>::::<:>::><>�:<:>�»:><»:<:>r:::r<>r::;:::>::<;:;:;:.::;:•;:;.:,:e;;;:::<::.
FROA1 TO DESCRIPTION
Well Contractor Ny^ame 7 :`1
5,35 9 d.�
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NC Well Contractor Certification Number 1 ;DtI t ER S �Sb C:f ir�slt.@asecF sekiLsi Ft£?i t� n£.2� .icab2e..... ..: i
Miller Well Drilling FROM TO DTAI4F.TFR THTCKNF.SS n^IgATF.RiAi.
Company Name ) � ff t,ft p in.. -5 ; < �°C
p � � ;;g €56'VtNTEti;CPab1R�.QRTF,'.1r,17titii:..eothe.�iiTaFcloSetc'lao ,.
• ,t ._-. FROM .1'O tNAN3A1'F:R '1'N3CKNF'SS 1FAIF.Rt.41r i
2.Well Construction Permit r:
List all applicable tell constnuction penntu(i.e:UIC,County,State,Variance,etc..) €t. ft. in.
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 't7SGItrNi`....: ::::. ...... . .....
FROAi I TO W.&AFETER SLOT SIZE TAIC:hESS M.ATERiAL
❑Agricultural ❑Mu�_,,.n�icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 91�esidential Water Supply(single) ft. ft. ;in
❑industrial/Commercial ❑Residential Water Supply(shared) ffiRCDk7T:'
❑Irrigation ❑Welts>100,000GPD FROM To I MATERIAL I F•DIPLACRMEWMETHOD&AIfOUNT
Non-Water Supply Well: q ft. ft.
❑Monitoring ❑Recovery !t. 2 i' ft. t
Injection Well: ft. £t
❑Aquifer Recharge ❑Groundwater Remediation
I�:S§i\ ia^33��EL I tw(tf :asilt
❑Aquifer Storage and Recovery ❑Salinity Barricr FROM TO NIATERIAL EMPLACEMENT rtiETUOD
❑Aquifer Test ❑Storinwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2ti ItTutTil3h:�:Li�:{dttxr aa�atioaaa s��ets.L;sea ss�ry .......
FROM TO DESCRIPTION'(color•hardness,soil/rock ty a—,rain size,elc.l
❑Geothermal(Heating/Cooling Return) i70±her(explain under r21 Remarks)
a r f ) ft. ,- ft. /�I A i4 31
4.Date Well(s)Completed: .9 � Well ID# aa ft fr t }.a }p
59.Well Location:Kaax
\ V&S , pt ft.
Facility/OwncrNamc Facility tD#(ifapplicabtc) ft..
L (V r
f it
Ern ft. ft.
l
PhysictlJ Address,City,and Zip
ft. ft 2023
iV - fE''r '4�. 'ar tiisxysn. tF`.v
County & Parcel Identification No.(PIN)
5b.Latitude and longitude in den ees/minutes/seconds or decimal degrees:
(if well field,one lavlong is suifcicnt)
� 22.Certif�',catlon lLo
=-�--
6.1s(are)the well(s): ❑Permanent or ❑Temporary Sic nature of Certified Well Contractor Date
�,,,� y sr:;ning rills iW'm,I her[nr ce!'Ii1)Yhar the,r r•Il(.d was(fiver:)vorstritem.w ir.at'cardtmcc 1vi7h
7.1s this a repair to an e7isting we11: ❑yes or "0 1= A'C•'C 02C.0l00 nr 15'A NCAC 03C'•020o;1'r/l Constnic'tion Standards and that a capr
J'rhts£s a repair,fill out known well construction it fnnnation and explain the nantre o1'ncc of this record has heen provided to the cell owner.
repair render k21 remarks section or on the back of this form.
23.Site diagram or additional yvell 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.SUBMITT'ANL LSTRUCTIONS
9."Total well depth below land surface: sC✓ (ft-
)
For multiple wells list all depots ifdiljerew(example-3 mane'and 2(a'100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below Coto of casing: t lst_) 24a. For Ali Wells: Original form to Division of Water Resources (DWR),
Information Frocussing Unit,1617 MSC,Raleigh.NC 27699-1617 lf'v.ater level is above casing,use
i
11.Borehole diameter: o (in.) 24b.For Injection Wells;Copy to DWR,Undergrowid Injection Control(iUC)
Program,16.16 MSC,Raleigh,NC 27699-1636
12.Well construction method: sr
au
(i.c.auger,rorary,cable,direct push,etc.) 24c•For Water SuDPIV aiad ODer-hoop Geothermal Return Wells:Copy to the
county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD•Copy to DWR,CCPCUA
13a.Yield(„wpm) Method of test:
Permll Playa-,1611 MSC,Raleigh,NC 27699-1 61 1
� �r '
13b.Disinfection type: Amount:. �®��``` f t cv Z
Form G W-I North Carolina Department of EnN iroumeutal Quality-Division of Water Resources Revised 6-6-201 S