GW1--01720_Well Construction - GW1_20240315

1
WELL CONSTRUCTION RECORD(G'W-I) For internal Use Only: _
I
1.We Cont[actor Information: e
I 1
�`� )trny //I� l iI
11 Gl a Etll, iJ- ( /1d�5 14.WATERZONES I II
FROM TO DESCRIPTION
Well 'ontactor\�wnc )5 ft, ) 1 ft. / .i
43 3 r I rt. 1 1J H. C QLlf NC Well Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if applicable)
MILLER WELL DRILLING FItOM •" ToIMt\IETER THICKNESS MA'1•ERL\L
Company Name •
0 ft. (03 ft. /. I' in, s��2 ( Py C-
I V '16.INNER CASING OR TUBING(geothermal closed-loop)' V
2.Well Construction Permit#: ` EROSI TO DIAMETER TiticKWRSR ( SIM I:MAI.
List all applicable well construction perutiiy/i.e.WC,Conti',State.Variance.r/c,1 ft. it. in. I
3.Well Use(cheek well use): ft. ft. j in.
Water Supply Well: 1?.SCREEN I' °
Fitom TO DIAMETER!- SLOT SIZE THICKNESS MMXI'ERIAI.
❑Agricultural CMunici al/Public ft. ft. 61.11
❑Geothermal(Heating/Cooling Supply) ralrgilential Water Supply(singlet ft. I ft. in.'
❑Industrial/Commercial CResidential Water Supply(shared) Ili.GROUT I
❑irrigation dwells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD S ANIMIST
Non-Water Supply Well: � ft 3, ft- nJ a; T rej _ •
❑Monitoring QRecovery rt. 2 0 fr. '.P12.flTIn,,• `�U�?LI
Injection Well: rt.`� ft.
• - QAquifcr Recharge ❑Groundwater Remediation
(9.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I F.MPLACF.IIF.NT METHOD
❑Aquilcr Test DStomiwI. ,atcr Drainage ft. ft. I,
❑Experimental Technology ❑Subsidence Control ft. ft.- I I'
❑Geothermal(Closed Loop) CTraecr 20.DRILLING LOG(attach additional sheets if necessary)
:'OGeothermal(Heating/C ooling-Reitini) COther.(explain undi:"r 1 Remarks)' PR°yI TO 1 DESCRIPTION(color.hardness.soil/rock ape„cast.size,etc.)
1. 11 1 rt. C i ctt I row,,
1.•Date Well(s)Completed:leted Well ID# .pjCo�7 J 1 rt. t.� rt• , ,,,,,,,„A. -
' ja.1, ell.Locatton .4 f �ni? ` ft. fL
Fat:ilit}/Ownerhame Facilityli)#(ifapplicable) ft. ft. I' �, �'( -
1 rr,.1 -5 :.. . ;CQ: )rrjv1 flv&/x1/6" ft, ft, I, f, MAR 1 c.. 2n?�t
D.
(,t UL
Phy:•ical Address,City,and Zip ,
p -2).REMARKSI I' ,111t0;:rtt%3,ii"':1 Pr ✓an y;1- ;
• li I Dv� J
Courtly pier,'el idondfic5tinn h'o.(PIA')
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if troll field,one 1st/long is sufficient; •' / 22.Certiftear n:
b tJ 7�7 \1 e
tat r�o ', , ,off y�\ ,�-/G
h.Is(are)lit weil(s): .ermpuent or q•I'smpaeary 'R'tri ircoftcrt lied Well Contactor-' I' I)IC. •
fly signing this Trn:.I here/;r ceriili'that the n'cllls)was(ware)constructed in ac•rm'dan:a nvph
9.Is this a repair to an existing well: -lrYcs. or a io -- /5,1.t'C,-IC t12C:O101t nr 15.4.\'CqC.(12C.0j00 Well Cnns,ructialr Standartfe and that a rapt
iflhis is a rehain,ffl nut Anown well construction in/onnatian and explain the nature of the o/'this record has been provided to the well owner. •
' repair under ir2/remarks season or on the hack q/this form. -
• - 23.Site diagram or additional well details:
t It.For Geoprohe/DPT or CRrsed-Loop Geothermal Wells having the same
You may use the hack of this page, provide additional well construction info
constriction,only 1 G W-) 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.
9.Total wet)depth below land surface: (ft.)
F,n multiple wall,list all depthstf different(example-3 ?hU'and 2(a l oo') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 5 (It) 24a, For All Wells: Original (omit,iu Division of Water Resources (DWR).
t•,„,,,,,,,,,,,,,..,,r"s.,,...,,,f..,,,,..••-�' - information Processing Unit,16l7 M:$i',Raleigh.VC 27609_iSt'r
I I;Borehole diunie`ter (in,) tab.For Injection Wells:Copy to'MCR.Underground Injection Control(ILXC')
Pio8tprt,. 16ib MSC.Raleigh NC 2•tir)9-163 G
12,Well construction method; Al- "- vi_(�
(i,k,auger,mmry,cable,direu push,t i j l 23c For Water Suoffiv and(.even•E.nrp Geotherroo1 Return Wells:Cep);to-the
county environmental health depantnypt of the county Whore iiuta`�fied °
'FOn lA`,�`I i3 Si~IerPL V 'LLS ONLY; 24d.For Watt_t•G ila,prodociew olv Ir 100,000 GPI):Copy to DWR,CCI+C1l,A
f"• • \ I1 tutulu r'iu t'n11,in I WC,)taic18114 21609-1t;I
I 1;4e Yield(gprit) i na.., M1 y,,,, �;#etln+;i of t9s1t• + f- .. I
' I Fi /4
L:111) 1)lainf'oetion typo:��,. Amount: ,„(,s, .t t` I
eitcrtn OW,I North Carolina Leypiutntcot of i?m'iruant ntid tliutli:y•e)It-lshsl of Water Resullry se