GW1--01344_Well Construction - GW1_20240304

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WELL CONSTRUCTION Ch .)(GW-1) For Internal U .-. ,"ly.�, '
1.Wel on r Information
T i
���� KGl?a2 14.WATER'ZONES..
• W• ell Contractor Name / FROM TO DESCRIPTION
. 2 s� . . �l/i ft. ft.
�1• ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING(for multi=cased wells)OR LINER(if ap licable) ` ..
." Miller•Well Drilling FROM TO - DIAMETER `THICKNESS MATERIAL
l� ft. J/_�/ ft. j in. J l 2? JC .
Company Name ) I `` �/ '161INNER CASING OR;TUBINIG(geothermal closed loop) '
2.Well Construction Permit#: (AJ 26/ (_�( (�' 1 FROM , TO DIAMETER THICKNESS "MATERIAL
•
List all applicable well construction permits(i.e.WC.County.State.Variance.etc.) ft. ft. in.
•
3.Well Use(check well use): ft. ft. in.
• 17.SCREEN'' -
Water.Supply Well: " -FROM TO DIAMETER SLOT SIZE THICKNESS
MATERIAL
Agricultural Municipal/Public ft. ft. ;in. •
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. `in.
Industrial/Commercial . D Residential Water Supply(shared) :.18.:GROU.T . 11 ..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 5ft. 3 ft. 6 l'6�1.., 17�/�
• Monitoring 0 Recovery a U ft* -Ib.�11 _ I r�
Injection Well: • ft. ft. T cLsl.+ (J+A���
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test f Stormwater Drainage. ft. ft. .
Experimental Technology . fSubsidence Control ft. ft.
Geothermal(Closed Loop) • DTracer 2ocDRILLiNGLOG(attach additional-sheets ifnecessaiy)
FROM TO DESCRIPTIOi.N(color,hardness,soil/rock type,grain size,etc.)
• Geothermal(Heating/Cooling Return) Other-(explain under Remarks) (� ft p�� ft. /r J•
4.Date Well(s)Complete--20 Well 1D# )�o ft. tow fr. v ' ; •�� " •
ft. ft. `•
5a.Well Locati n: _
ft. ' ft. ",d
p^a i
Facility/Owner ame Facility fapplicable) "
ft. ft. r %A. -41 1�V LI
`- I9 f fL fr.- MNK �C
• ' 22/., • T 1i /1 1 ) urpA� . 0 2074 •
P1 'i I Address City,and Zip / ft. ft.
'21:REMARKS , - ':.tipt)tr;•kxte"t i �evr.:4-, ''. >.
County Parcel Identification No.(PIN)
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511 Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
• 25" O4i lJ/�7' N 0 rr S% • l� 2 W /. 9�7
6.is(are)the well(s) ermanent or jTemporary Signature" fCertified WeILContractor • Date /
' By signing this form./hereby certify that the well(s)was(Were)constructed in accordance
7.is this a repair to an existing well: f Yes or El< with/5A N(AC 02C.0100 or liA NCAC 02C.0200 Well Construction Standards and that a
• If this is a repair„fill out known well consIruciion information and explain the nature o f the copy of this record has been provided to the well owner.
repair under�21 remarks 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 I GW-I is needed. Indicate TOTAL NUMBER dwells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS ,
• -9,Total well depth below land surface:" (..e60 . (ft.)
24a. For All Wells: Submit this form within,30 days of completion of well
• For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following: .'; -
10.Static water level below top of casing: (U 4 (ft.) Division of Water Resources,Information Processing Unit,
, if wetter level is ahove casing.use t •
/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11 Borehole diameter: ' (0 (in.) ) 24b. For Injection Wells: In addition to sending the form to the address in 24a
•�i?,/� • •" above,also submit one copy of.this form within 30 days of completion of well
•12.Well construction method:' ! to construction to the following:
• (i.e.auger,rotary•cable,direct push,etc.) , . _
/
Division of Water Resources,'Underground injection Control Program,
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FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
• 13a.Yield(gpm) if• 0 Method of test: J r 24c. For Water Supply&•injection Wells: In addition to sending the form'to
the address(es) above, also submit one copy of this form within 30'days of
�F
13b.Disinfection type: 1' " Amount: ' /"I completion of well construction to the county health department of the county
where constructed:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016