GW1--02413_Well Construction - GW1_20240422

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WELL CONSTRUCTION RECORD(GW-1) Fur internal Use Only:
1.Well Contractor Information: 1
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•�(01� �?} ,1:V .Nti.arERzo:�ss 1 I
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I� �� � �jr)1!l � ! FROM ) to I UksC'ItlhllON -,
Well Contractor Name !
t� 792 ft. 22 fr.
(� � ' ft. J� ft- I I
NC Well Coning or Certification Number I 15.OUTER CASING(for multi-cased)dells)OR LINER(if applicable) I ,
MILLER WELL DRILLING FROM '1'O DIAIIETER• 1 -r111C'KNE:ss MATERIAL
j , fr, ft. ✓
Company Name
v �� -� 'in. S.D��2! �1�
�f r 16.INNER CASING OR TUBING(geothermal closed-loop)
#: fill 222'3Q, '/I /, FROM TO ( DIAMETER' THICKNESS )14TER1.\I.
2.Well Construction Permit /� I
List all applicable �1f construction permits(i.e.WC.Colony.Slate.i in ianre.rue.1 It. ft. in. I(
t,
3.Well Use(check well use): fr. ft. J' in.
Water Supply Well: I i.SCREEN 1 •
FROM •I'O DIAMETER,' I SLOT SIZE THICKNESS I }IATERIAL
❑Agricultural DNlunicipal!Public i ft. ft. in! I
❑Geothermal(Heating/Cooling Supply) Cential Water Supply(singlet ft. i I fr. in. I I
❑lndustriat'Commercial - \=Residential Water Supply(shared) j IS.GROUT -
DT ri ration C:Wells>100.000 GPD I l FROM TO I MATERIAL. / r..MPPI..4CEMENTT METHOD&AMcn.NT
Non-Water'Supply Well: i! it. v ft. TC-.'�-a:.. . Yri(-r r;_:r1 I
Q�1oI)itoring _Recover I ' it. fr. t
G Lnfl/ _ �vf , -J
Injection Well: I C S
it. ft.
❑Aquifer Recharge ❑GroundwaterRemediation I I ,
I 19.SAND/GRAVEL PACK(if applicable)
❑Agwiler Storage and Recovery CSalinity Barrier FROM TO I M&TERIAt.. E:N1Pi.ACFMFITMFTIIUD
❑Aquifer Test QStonnwater Drainage It. H. -
❑Experimental Technology ❑Subsidence Control ft. ft. )
❑Geothermal(Closed Loop) ❑Tracer 120.DRILLING LOG(attach addition!sheets ifnecessars)
❑Geothcmtal(I lcaling/Cooling Return) QOther(explain under'+'_I Remarks) FROMTo DF.SCREP.'r1O\(color.hardnes soil/rock ape min+ize,crc.1
4,Date Well(s)C:ompleted:`1 -1 C�- 4 „6'eil IDo ft• , .~;j; ft• I `, ),_ "'l 4t` - ' .
ft. ft. .J I' _
5a.Well Location: ,„_. ..-, ,.-.-.,a, )r :-.
ft. ft. �'t, .t...'C.f �3 '1...,t..0
Facillity:Ow)nerName ll Facil1i:ylBs(if applicable) I It. ft. I Ape 2 G Zf174
1�avj 2��1J l��lt i (1 l :4 1ltJ(+UF1✓0, NC I ft. ft. ( APR
Physical Address,City,and Zipft. fr. < U ^^:�di`"e? tirtF
1l' 21.REMARKS `[j::t✓�.�
1chGt(�SCDirl .
County Parcel identification No.IPIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
. (if well field,one lag/long is sufficient; 22.Certificatio
n.:�5"' o :(oLI N -X3© 1491,06' W /r( 41,)
�t L" t'
_- 6.Is(are)the well(s): 2 anent or ❑Temporary Sianar)re of Certified Well C'uiitractus Date
/ kr.signing title fi»•m,/he•rci,r Ccl/ill'thatthe tivlit.siISJSilscsciconstructed in:7C'r'e1:,JC:WC.:Uili
7.Is this a repair to an existing well: DYes or o 15,1 A MCC(1.C'sow,.a•15,1.VCAC n2r 0200 Well i]ens:ruction Standards and that a r,y,r
II fhb;is a repair.fill out/nown we!!ewurrtrtion inlbrnuniou and explain the nrmnr gfihe: of riot my ord has lees;prrn,:ded to me aril owner.
repair tinder fr2!Marks sertia,n or an the hack nj':hi sinnn. .
23.Site diagram or additional well:details: .
8.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the sonic You may use the hack of this page'io provide additional\cell construction info •
construction,only I GW-1 is needed. Indicate TOTAI.NUMBER of well, (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: I
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��(� 2a.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2_, f lee/ (ft.)
Pnr,mdtiple wens list ull depths f different ferung:/r-3�a;'f(1'and'ra,l00.1 ) Submit this GW-1 within 30 clays til well completion per the following:
10.Static water level below top of casing:
aft) 24a, For All Wells: Original fuel tip Division of Water Rest.mrces I'D1�it).
.r.......•..r,.,.•r:.,,.+.....�<.<.r.,:,,.,.. .. mfarmation Processing 1.-- 1617 Nis; .Ralei_ah.NC 2 76oO_16I'
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• t i.Borehole diameter: �� On.) 2=1b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
r Program. 1636 MSC.Raleigh,NC 21699-1636
12.Well construction method: fi l �;-ILK raj 24c.For Water Supply and Open-LGeothermal odp Return Wells:Copy to lilt:(i.e.au cr.rotary,cable.direct push.ire.) - /
county env:rotimental health dcpartmbnt attic county where installed
FOF.-WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing tiler!100.000 GPD:Copy to DWR.CC'PCUA
13a.Yield(gpm) ,6 Method of test: hi/K.
Permit Program, 1611 MSC,Ralcigh)NC 27699-t6!1
13h.Disinfection type: 4-4 Amount: //1/ r:vp - `
Fenn.OW-1 North Carolina Department or Environmental Quality-Division or Water Resource, Revised 6-6_(IIS