GW1--01057_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I; '
1.We Contractor Information:y� I' '. t
1 1.F o rney'1 Iota et I �.i n$ 14.WATER ZONES l
Well C tractor!ant FRO
\f I TO DESCRIPTION _
7��ft, 2 9�f t- r Qk.y.
���-', ft. ft. I i
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased'wells)OR LINER(if applicable)
MILLER WELL DRILLING FROM TO I DIAMETER THICKNESS MATERIAL
t) ft. ft- Ca in.
S l` //I
Company Name os 7 (/L r
� , j 16.INNER C\SLHGG OR TUBING(geothermal closed-loop)
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2.Well Construction Permit#: ( FROM TO i DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U]C,County,State,Variance,etc.) ft. ft I in.
3:Well Use(check well use): • ft. ft in.
• Water Supply Well: 17.SCREEN
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FROM i TO I DIAMETER. SLOT SIZE THICKNESS I MATERIAL
❑Agricultural • OVlunicipal/Ptiblic ft. I ft. in.
❑Geothermal(Heating/Cooling Supply) 1dential Water Supply(single) ft. ft. in,`
❑Industrial/Commercial :Residential Water Supply(shared) 18.GROUT '
❑Irrigation - ❑Wells>100,000 GPO FROM TO ' MATERIAL I EMPLACEMENT METHOD Z.':AMOUNT
Non-Water Supply Well: Gi it. 10 ft. 1
- ❑Monitoring , ❑Recovery ft. ft ��� �~ ��
Injection Well: ft. ft.
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DAquifer Recharge ❑Groundwater Remediation • '
19.SAND/GRAVEL PACK(if applicable),
❑Aquifer Storage and Recovery ❑Salinity Banier FROM TO 'MATERIAL I-EMPLACF.MENT.METHOD '
0 Aquifer Test ❑StormwaterDrainage ft. ft.
-❑Experimental Technology ❑Subsidence Control ft. - ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional,sheets if necessary) ,.
FROM TO I DESCRIPTION(rnto hardness.soil/reek type.etnih size,etc)❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ID ft.
9 ft I f 1 ��)
7 Cvl twe A'S (�
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4.Date Well(s)Completeil: t-2 25 Well ID# 4t) ft. W ft. I
5 . Yell Location: 1 ft. ft.
ff/e. �4 keo G ft. ft.
Facility/Owner Nam Facility ID#(if applicable) It. ft. ,•-+
73 g 3 �' to 4 Ens)- J-. Hsu-,1 )e. It. ft �:, ��,r ;y=
Ph'i 1 Address.City.andl ip ft ft Lf
21.RE1IARES frt.(S i 2 )flryA
County Parcel Identification No.(PIN) Y- �}�t�'rs CUL`7
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• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DbG't,7 aln
(if well field,one lavlong is sufficient) 22.Certiticatiot
3-6°°241 i. N 73° (.59, 69 w yri ' ,
aig-L- / 1-29-23 .
6.Is are the wells: Signature of Certitr:/ A.I m ,
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-ed.VsellC Contractor ' ' -
Is(are) () 2<manent or ❑TemporaryDate
By signing this•font,I hereby certj'that the well(s)was(were)constructed in accordance tt'ith
. ' 7,Is this/a repair to an existing well: GYes or t'o ]a.4 AZ.IC 02C.WOO or 154 sC;C 02C..000 Well Co;:stnmtion Standarir and that a cope
If this is a repiir,fill out knows,well construction n fonsratien and explain drt nature qT the of this record has been provided to tne!t,•elt nutier. ,
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repair under�2I remarks section or en the back of this form.
23.Site diagram or additionalwell details:
S.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 1 GW-1 is needed, Indicate TOTAL NrUI f3ER of wells - (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'S{(,e-) f
Formultiple wells list all depths if different(example-@200'and 2@100) (ft)" Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top.of casing: 24a. For All Wells: Original foam to Division of Water Resources (DWR),(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Infection Wells:Copy,to DWR,Underground Injection Control(ICC)
�//{e` Program.1636 MSC.Raleigh,NC;27699-1636
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• 12.Well construction method: !7 r j/' gal-Or" i'
(i.e.a er,rot 24c.For Rater Supply and Open-Loop Geothermal Return Wells:Copy to the
ug any,cablz,daect pusl> ztc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingI Over 100,000 GPD:Copy to DWR,CCPCUA
• Permit Program,1611 MSC,Raleigh;NC 27699-1611
I3a-Yield(gpm) 3 0 Method of test: i/�
a ( s f I
f
13b.Disinfection type: � ! 1-1 Amount: (/l Cop i'
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Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20 i S '
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