GW1--03990_Well Construction - GW1_20230612

WEL1f CONSTRUCTION RECORD QW-D For internal Use Only:
1.Well Contractor1nformation: `
..:. ..... .. .: ... .. ,.::co-._,.:.... ...
Well Contractor NaaMe
FRO MTO DESCT2tPTTOY s
NC Well Contractor Certification Number
Miller Well Drilling FROni TO DiANIETF,R I TMCKNESS J MATERl.At.
. + .
Company Name �7r��r ), Pvc A 2il
6.t!f uEt2 CA§Ei G'Dii r(31'1f `eGthe i i-E ct��ec=loop)
2.Well Construction Permit 4: 1A02L)720C04I ta FROP1I ro NiATERIAt.
List ail applicable)cell const uctior pennits(i.e.WC.County.State.Mortance,etc,)
i
3.Well Use(check-,you use): . ft. fL in. I I
Water Supp3✓Well: �
FROM I TO I DIAMETER I SLOTSTZE TRiCi:N&SS Ni:aTECtA-
❑Agricultural ❑hiunicipaVPublic : Ft. ft. in.
❑Geothermal(Heating/Cooling Supply) G Residential Water Supply(single) ft. ic- in.
❑Industial/Commercial ❑Residential WzterStrppiy(shared)
❑urination ❑Welds>100,000 GPD FROi1. TO QA t F.RthL ..\T 1:aTTyOD S AarOu T '
Non-'.rater Supply Well: �� ts. ft. P, i J ;.M rfjc^
❑Nfonitoring ❑Recovery 7 ft. `? ft. n
1"19' Tt171"I Injection Well:
'� ft rt. r
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifcr Storage and Recovery ❑Salini Barrio
tI b Ciy Salinity FROM I TO I MATERIAL EMPLACEMENT BIETHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidenc_e Control f:. fr.
❑Geothermal(Closed Loop) ❑Tracer It:�RIIa3nJT1 :?r40fditac :waditioiLsZeets: rgeessacv7»:'>:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) MON! TO D oe,E,CRIMON(color,hardness,soiUrocl tv erzin size.etc.l
�� ft. �� fr• Q A I q}til,L`i2
4. Date Weil s Coln leted:A&1LP-2� � � I j
() P dv'e8l1lD# `(�(� ft' �srt fr' ' I/ G_c1 �,JC;•IL- !
5a.Well Location: It.
ft. ft. IL.�~� L
Facility i
/0wncrName �t ( Facility ID#(ifapplicabic) ft• ft•
nnn
d z � ° .lJd1'�li(l7i�0 3 [,%— sU}'',1')A\/ ft. ✓ n
Physical Address,City and Zip ft. ft.
II1fCf tli.SJc fl PPCY± "U1
Coonty Parcel Identification No.(PIN) I
s
5b.Latitude and longitude in den ees/minutes/secunds or decimal degrees: .t
(it'wcllficI one IaUlonc is sufficicrit) £a 'N "•Certafcad
�� 1
6.Is(are)the well's): ❑Permanent or ❑Temporary Signature`of Certified Well Contactor Date r,
E,sr min�;his/orn:,1 hvrr n•„•r,rrti/j•that rhr rr1l(si:gas err;)rurstrrrtcd ir accardancr nigh
i.5s this a repair to zL esist hg rve11: 0-Yes o: -EI'ao 1 ?:vCP.0 03C.0100 or 15.4 IJC.I C 02C.0200 7:1rl1 Constn-mior,Stardordv and that a cap;•
Tf th s is a repair,ftJl oru/nova well construction information and explain the natr re of'the 0f this record has!;can provided to the urll onze,
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/IDPT or Closed-Loop Geothermal Wells having the same YOU may use the back of this page to provide additional well construction info
construction,only I GNV 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks BOx).You may also attach additional pages if necesary.
drilled:
p ^J 24.SUBilla'?TTAL E STRUCTiONS
9.'l•otal well depth below land surface: "'7'.!-0 ft
For mu hip It,wells list all deptlss if difjjerent(example-3 m 00'and 2(5100') ( } Submit thi GW-1 within 30 days of well completion per the ffoltotr in-:
10.Static seater level below top of casing: 1V (FA) 242. For All Welds: Original form to Division of Water Resources (DWR).
!f varer level is above easing use"+" information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.BorehoIe diameter: (-,) 24b.For iniection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r G) p/51
(i.e.auger,rotary.cablc,-dircct posh,etc.) 24c-For Water Su�niv and©Dew-Loop Geothermal Return Wells:Copy to dre
county environmental health department of the count)-where installed
FOR WATER SUPPLY WELLS ONLY:
ry 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm} 1Elethod of test: /d Pitt Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.1Disinfection type: R' it Amount: 'At i120
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rasotlrc I s
Revised 6-6-2018