GW1--02483_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD(GW-1) Fur internal Use Only: i
1.Well Contractor Information: j i
ierI fa'06� IQYII i i(1.40 Cl) !l J in5 ' 14.�1ATERZONES 1 i ^
FROM 1 TO 1 DESCKIPTION I
Well amc / /l2�ft. ��6 1 ft. � I I .
1 rt. ft.
NC'Well Contractor Certification Number 15.OUTER CASING(for multi-cased well§)OR LINER(if applicable)
MILLER WELL DRILLING FROM I TO I IN\IETEtt I THICKNESS MATERIAL.
i • ft, l ,;--.)).-7 fr- 1 t s1 ,in. I.S/ % (: .- c.-.� 1
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 04�. FROM TO I DIAMETER THICKNESS at tTEIt!.sl.
rt. ft. :in.
List all applicable well construction permits(1:t.UiC.,County.State.Farirrnre.etch
ft, ft I II in.
3.Well Use(check well use): '
17.SCREEN I. '
Water Supply Well: FROM I TO DIAMETER sloTsr/.E I TIIICKNES. tI:CCERIAI.
❑Agricultural Municipal/Public ft. I ft. in.
DGeothennal(licatinglCooling Supply) ential Water Supply(singlet ft. I. ft. in. I 1
Dlndustrial'Commeroial ' GResidential Water Supply(shared) 1 II.GROUT
❑irrigation ❑Weila:::-100.000 GPO I FROM TO MATERIAL E>li'L.tCEMENT METHOD&AMOL NT 1
Non-Water Supply Well: V r-,,ft. 2 ft. jay-1-lf(,t nd iqi po4 .
❑Monitoring GRecover• ft. l ' ft.
injection Well:
ft. ft. i
❑Aquifer Recharge EGroundwatcr Rcmediation 19.SAtiD/GRAt'EL PACK(it'applicable)
CAqui ler Storage and Recovery GSalinity Barrier ( mom TO I tlaTt:Rinl. I EMPI.ACRt1F.NT METHOD i.
DAqui far Test GStonnwater Drainage l ft. ft. 1 .
❑L'zpedmentai Technology -Subsidence Control ft. It.
r 20.DRILLING LOG(attach additional sheets if necessary)
DGcothcmtal(Closed Loop) MT-racer .
FRO>( TO DESCRIPTION(color.hardness,soil/rock tote,train size.etc.)
DGeothermal(heating/Cooling Return) GOther(explain under:121 Remarks) D n I ft. • (Gk../
3-,24 Vt .
4.Date Well(s)Completed: Well ID# rt- -.) ft, is - (Gk.. )'�
ft. ft.
Sa.Well
{{Location: (741 :Ve, f6j ym a 1 fr. ft. '
( Facility lf)P 11 iir(Doe) rt. 'ft. I I. - ..,. .... .. ..
Facility%Ow('n�er Name �j J pP •• f
2 7`i Q j P fi r`/.�Ci'// ( Iv ft. ft. ' a 'E L.,r . 'Q.,..1 �l 1,„
Physical Address,City,and Zip J ✓ APR 2 ' 20 74
Lk`AA
n 21.REMARKS
County Parcel Identification No.(PIN;
Ire_; '..;x ., 77.--,^..`rJ.'a::.'t-A UeA
P
- Li:' C:rf0:3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )
(if well field,one lat/long is sufficient) 22,Certificatio ' 1 ';1 7 i
3 `°Li 41,31 N -Y5 c f27• W 11/1 / , � ! , - ,�
6.Is(are)the a•etl(s): 'ermanent or DTemporar Signaure oi'Ccrtilied\t�cll Contractor Date
By signing this lam.1 hereby ccr•tiii'that the it'ciltsi was i K'crcl construe:red in aCCor'Ci:a7Cc w.i117 ,
7.Is this a repair to an existing well: DYes or f3N11----- (5.1 NC.IL n2C.aian or 15.4.VCAC n2i'.020h)tell Construction.Standards and that a r.grr
Ifthi.s is a repair.fill out dnorn well construction iolbnnatier7 and explain the nature ofih,. .4(this record has heen Fronded is the sic•!!art
I('pair under#27 remarks section or on the hack of this Jinni.
23.Site diagram or additional well details:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sang You may use the hack of this page to provide additional well construction info
construction,only I GW-t is needed. Indicate TOTAL NUM13PR of wells (add'See Over'in Remarks Box).You may also attach additional Pages if necessary
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drilled: •
24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: GO( , (ft.) Submit this Gel'-1 within 30 days of well completion per the following:
For multiple well..list all depths ii.diiferent texantple-3'a,2rjfi'and 2ra,it)0'1 ' •
�flfl'y�!! 24a. For AU Wells: Original form to Division of Water Resot.rces (DWR).
10.Static water level below top of casing: 2Dr) (fr) Information Processing Unit,1617\ISC.Raleigh.NC 27699-1 61'
24b.Fur Injection Wells:Coot'tt:DWR.L:ndcrground Injection Control (ICC•)
11.Borehole diameter: .l/ (in.) ��,! Program 1636 DISC.Raleieh,V I' �699-1636
12.Well construction method: err. )�1/)��f� Z4c.For�i'ater Sappy and Opeln-Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary,cook,direct push,etc.) county environmental health depart;itent of the county where installed
FOR WATER SUPPLY W'F,LLS(3ALY'c 24d_For Water Wells producing'over 100.000 GPD: Copy to DWR.CC•PC•t.:A
Pennit Program,1611 MSC,Ralcintl.NC 2'.699-161 1
13a.Yield(gpm) I :,/� Method of test: I k" d
13b.Disinfection type: • L k' Amount: I/4 t A_'
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Form CiW-1 North Carolina Department of Environntsnta l Quality-Division of Water Resuae e Revised 6-5-2015
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