GW1--03992_Well Construction - GW1_20230612

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WELL,CONSTRUCTION!, �1.. _J(G.W-1) For Internal U
1.Wel on r Information,
14.WATER ZONES"
Well Contractor Name FROM TO DESCRIPTION
Zan� p j ft. ft. -
a v ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if applicable)
Miller Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
Company Name U! in. J
�� �y ] t FROM
INNER CASING OR TUB[AM Teofhe mat cl THICKNESS
`j
2.Well Construction Permit#: (�( FROM TO DIAMETER THICKNESS MATERIAL
List all-applicahk ire//construction permits(i.e.WC.County,Slate, Vorianc•e,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN - -
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Pggid.ntial Water Supply(single) ft. ft. in.
—1 Industrial/Commercial DResidential Water Supply(shared) -- :.-
18.GROUT:..!,
Irrl atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring E)Recovery ft. U fr. To
Injection Well: b
Aquifer Recharge; DGroundwater Remediation ft. ft.
19.SANDIGRAS'EL PACK :a'liiable) .:"
Aquifer Storage and Recovery nSalinityBarrier FROM TO MATERIAL EMPLACEMENTM ETI IOD
Aquifer Test E]Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.:.DRiLLiNG LQG(attach additiorial-sheets ifnecessarv)
R
TO DESCRIPTION(color,hardness,soil/rock e,wain size,etc.)
GeotFierrnal(Heating/Cooling Return) Other(explain under#21 Remarks) ,l ft
4.Sate Well(s)Complete Well ID# bay ft. O ft.
Sa.WlIell Locati n: _ e
Facility/Owner Mame Facility'ID# applicable) ft. ft.
ft. ft. jUN 22
�
J
lJi� 1 JYJ7��1�
Ply}�i a1 Address.City,and Zi �—' ft. ft. 7 ,r e
/`J/ p )..IC"
21:REMARKS . �1 �.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lat/long is sufficient) 22.Certification:N Z2 f 3°59 , 2 W
6.is(are)the well(;) ermanent or Temporary Signature fCertified Well Contractor' Date `
)v signing lhis•firnh,1 herehv certify that the nrel/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or Yo with 15A NCAC 02C.(100 or 15.4 NCAC 02C'.0200 Well Cohs1ruciion Standards and that a
If this is a repair fill out known well construction infirniatan and explain the nolure of the copy gf this record has been provided to the n•ell owner. '
repair under-1 21 reinarkr.section or on the hack 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 site details.or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ol'wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.'Total well depth below land surface:
�� .24a. For All Wells: Submit this form within 30 days of completion of well
For nntllip/e u•e//s•/Let all depthsifdrfferent(exanip/e-_f a 200'and 2 a,100') construction t0 the following:
10.Static water level below top of casing: r� (ft.) Division of Water Resources,Information Processing Unit,
If water/erel is chore casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: U�tl� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm) Method of test: fiv 24c. For Water Supply& Iniection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: AIL
Amount: hl completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016