GW1--04793_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We
4 Contractor Information:
50 rd lie al cis,_ CA n c I4 AVATER-ZOATES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number is.OUTER CASING(forimulh cased wells:ORt1NER(if ap hcatile) .
Miller Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
D ft. 7(a ft, (s) tn. 5D R 2) P/C
Company Name (� t4.INNER CASINGOR:TItBING(geothermal closed-loop): -
2.Well Construction Permit#: V� �j 2-I)O 3 FROM TO DIAMETER THICKNESS MATERIAI.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in,
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Er estdential Water Supply(single) ft ft. in,
❑industrial/Commercial ❑Residential Water Supply(shared) 1ff:GROUT
❑irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL F.\IPLACF.MENT METHOD&AMOUNT
Non-Water Supply Well: b tt. 3 ft. ?U1rt 1 W1. l v W1p
❑Monitoring ❑Recovery 3 ft. 7v ft. tT 1_/lt �V mp
injection Well: CU
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
>19:SANDiGRAVEL FACIK(it applicable) %?=
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test• ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20IDRILLING10G(attach additional sheeisf'hecessaiv)<�..
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. .20 ft. (I 1Q`(1
4.Date Well(s)Completed: -Well ID# 20 ft. 5V ft. /tit t r, I Rom},
ft. ft. rPr tl.� .J K-
5a.WellLocation: 58 'IOU f7/i,?,Yti-)-c SoI;A
f YV l 2,e_fl t't. R.
Facility/Owner Name (� f- l Facility t011(if applicable)
fL ft.
i-01- `i 7 f-t 1'i d i-I 1)e ft, ft. R E C I 1L
1 ?Li n•u 5 aSd; °k
I Address,City,and ip
D
ft. ft as i b �
Y'
CountyNcvi21`13EMARK6°_� : h 6X .n ryryn .-.
Parcel Identification No.(PIN)
In r.adir.n Prt^C lint
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . ;a
(if wcll field,one lat/long is sufficient) 22.Certificati n:
,,5., 057 „ 3 N aV30 .711 r 7i w e ,, -z/�.� . 1-27-22
� Si o Certified Well .ontrac or Date
. 6.Is(are)the well(s): El1Crmanent or ❑Temporary
�� By signing this turns,!hereby reef/fj•that the well(s)wits(were)constructed in accordance with
7.Is this a repair to an existing well: ID Yes or Lr'1No 15A NCAC 02C.0100 or 1.5.4 NCAC 02C.0200 Well Construction Standards and that a copy
If tins is a repair,fill out known well construction in/bnnatimn and explain the nature of the of this record has been provided to the well owner.
repair under#21 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 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.SUBMITTAL INSTRUCTIONS
LIDO
9.Total well depth below land surface: �i vl/ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if-different(example-3(01200'and-(a;/Do')
I 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Q (ft.) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
If water level is above casing,use'•+•'
11,Borehole diameter b (in.) 24b.For injection Wells: Copy to DWR,Underground injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 11--)1 V 0 ti r V 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,PermitCCPCUA
L� Program,1611 MSC,Raleigh,NC 27699-161 1
1
13a.Yield(gpm) Method of test: fli r
13b.Disinfection type: }If I+ Amount: JIU cup
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources -- - Revised 6-6-2018