GW1--01348_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD (GW-1) • For Internal Use Only:
1.Well ontr ctor Information:
0i,1 r)�,y , )Ie,b- Co! I1 o S I4 41 R>ZONGS: .,<
WellContractor A to FROM TO DESCRIPTION
L 33 98 ft. ADD ft' C/fir-
ft ft.
NC Well Contractor Certification Number
1o:OlITPRCASuVG(foi:mufti-caseiliie.11 DIIIINAWfifiM tiia'hte) ;. ,.a*,:
Miller Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
0 ft. F.5
J ft. 1 •_ in •/�S- 5 )
Company Name ��tt n (1 c J W lJ P¢-/
(9,22
� - 2�� t6 ItNER CASING OR Tt1Bll\G f eothermal ctoced.Ioop) _
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
—
List all applicable well construction pennits,(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): it, ft. in.
13 S:CREEhT.,:
Water Supply Well: . ; ,;.,......:.,,........::..::......
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mutri al/Public - ft. ft I n,
❑Geothermal(Heating/Cooling Supply)" ftesidential Water Supply(single)
ft. iL In
❑Industrial/Commercial ❑Residential Water Supply(shared) ..,;:;;:.:.
❑Irligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT AfF,THOD&AMOUNT
`l
Non-Rater Supply Well: 0 tt 2 ft. l� ��
❑Monitoring ❑Recovery 3 ft. q0J ft. /2_ _1 i T�iJv�-r_N
injection Well: n. b ft. � t
❑Aquifer Recharge 0 Groundwater Remediation
19i'.S LNDIGRAV'EL<PACK:(if apPlseableL ;>
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT hIETHOD
•
❑Aquifer Test • ❑Stormwater Drainage It. ft.
❑Experimental.Technology 0 Subsidence Control ft. ft.
f
) ...::i OGeothermal(Closed Loop) OTracer 20�11kICLII>,'G:T:OG:{attacL addttiaualsbeets:ffnecessaix
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.l
ft. ft. ,
(jay d-ira.L4.I
4.Date Well(s)Completed:t e) 7 622 Well ID#
/ ft. I�D ft. (7/'OLYJIre
ft. ft.
5a.Well Location: /t/� ,
ft.
Facili /OwncrN`ame Facility ID#(if applicable) ft. ft.
1422 I u5gpi-Hee, V ,,„ .sv/l k ft. ft. ' MAR 6 ii 2'024
Ph teal Address,City,and Zip ft. ft.
tri of matim P :s.a.c..rn v t
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlone is sufficient) •
C� CO p 22.yincation%/ -
° Ota ' q I9 N C / Tv7' 0O w Cl� Z7'Z26.Is(are)the well(s): 13 ermanent or ❑TemporarySign Certifintractor Dale
By signing thisfw•m,1 hereby eerri/$that the well(s)was(were)c•onstrtalcd in accordance with
7.Is this a repair to an existing well: ❑Yes or . 0 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction it fanaation and explain the nature of the of this record has been presided 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 construction info
• construction,only 1 OW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
P j O��t 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: (ft)
wells list all depthsfd(different(example-3 d 200t'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
For multiple
`�
10.Static water level below top of casing: / (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
limner level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: �( (in.) 24b.For injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /Y ki- ✓(f 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,CCPCUA
13a.Yield Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 I
(gpm) Method of test: I
13b,Disinfection type: H ry'1 Amount: IA CUp
•
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources : Revised 6-6-2018