GW1--03189_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD IGW-l) For internal Use Only: i 1.Well Contractor Information:
rercy Rees.. , 1a.WATER ZONES
or\amc FROM 1'0 I of.scatr110N
Well Conlra
0 ft. 35 R. cr
3s ri. I{"3Or`' C-.Arra ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(i►ap licahle) I •
MILLER WELL DRILLING 1 FKOSI rt TO ft. DIAMETER in. THICKNESS ,,\TERI,,
•
Company Name ^� 16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: 6 AAl' ' t/y`4 FROM TO DIAMETER THICKNESS \11TEAL\L
List all applicable well construction permits(i.e.I.K.County.State.Variance.etc.) ft. fl. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FKOVI I TO BLAME TER SLOT SIZE 'LUICKSESS MATERIAL
❑Agricultural '� Municipal/Public ft. ft. in. -
❑Geothermmal(Heating/Cooling Supply) iRes1idential Water Supply(singlet fr. ft. is
❑Industrial Commercial :Residential Water Supply(shared) I IS.GROUT
❑irrigation _Wells 100,000 GPD FROM TO MATERIAL ' EStPl..\C EMEST S11:TROD&AMO_ST
Non-Water Supply Well: d ft- a ft- Pacl6tt4:g Pc..;e.4
❑Monitoring Recovery ft. ft.
Injection Well: •
ft. ft.
•
°Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if appticabk)
❑Aquifer Storage and Recovery °Salinity Barrier FROM TO %INTF.RIAI. Ey1PI.ACFSIF.NT METHOD
❑Aquifer Test :StomnwaterDrainage 1
rt. ft.
❑Lxperimental Technology -Subsidence Control ft. ft.
❑Geothermal(Closed Loop) I=Tracer 20.DRILLING LOG(attach additional sheets if aecessan)
❑Geothermal(lleating/Cowling Return) Other(explain under..21 Remarks) FROM TO DEKRIPTIOS(croMr.hardness soil/rock rape.grain size.etc.)
It. .av ft. C. .0 v
4.Date Wells)Completed:.�y)Gb 4 Well i139 ad rt. 3S' ft C�fY04y t i&. a
52..Well Location:: 3 JS-It. i G0 f t' C-1!'et,w i 4s-c(2'.['7'.kne. , S f tM
t`t C K., U c`, at't`L !too ft. :1 (S-ft. -,. ra.,.`t�-e toss f ,16 5 eh" .
FFffaa City di rOw,ner.' ^ Facility DP(if applicable) Li IS-". y3©f`• ( rav,'t I.
(D Irf\e `'� e5u\iL- id C- I ft. ft. R ,_..t.,i...; V 1._.Li
Physical Address,City,and Lip ft. ft.
CL&f aS9a 4 555LW A0 l7s {y'
21.REMARKS HI 2 z. zn24
County Parcel identification No.iPIN>
-.zr s7'81
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1. r,C;;312/0 •
(if well field,one latik:ng is sufficient; 22.Certification:
35. 06308-° N CP) %a3(c:3° NY6.Is(are)the n ell(s): 3'Pe��rmanent or ❑Temporary St inure of Certified Well Contractor Date
1 By signing this horn:.I hereby ccrriii' s that the c//fst tens;ssrret construrted in accordance with
7.Is this a repair to an existing well: :Yes or IBNo /5d KC.lC 02C.0!00 or/sn V'CA<'roc n20O Well C'vestrur,inn Standards and that tr copy
I/this is a repair.RI out blown well construction information and explain the nature oldie of this record has keen provided to the well owner.
repair under b?;remorks section or on the hack of this.fnnn
23.Ske diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well construction info
construction,only 1 GW-1 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 well depth below land surface: 430 (ft.)
For multiple trite list all depths i/Ji/h':en:lexampic-3',2Iifi and erg too t Submit this GW-1 within 30 days of well completion per the following:
20 (11')
24a. For ..0 Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: d (h) information Processing Unit.1617 MSC.Raleigh.NC 27699-I61'
If wafer level is above casino.rote
11.Borehole diameter: CO
24b.For Injection Wells:Copy to DWR. (DX)Underground Injection Control(I )
A (in.) Program. 1636 MSC.Raleigh.NC 27699-1636
12.Well construction method: A:C C esto-cy 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
(i.e.auger,rotary.cable.direct push.etc.) county ens iro,mental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water\yells producing over 100.000 GPD:Copy to DWR.CCPCUA
13a.Yield(gpm) I Method of test: A y r a Penni!Program,1611 MSC.Raleigh.NC 27699-1611
13b.Disinfection type: 1-1+-l-f Amount: V 4 (-AA?
Form OW-1 North Carolina Department of Losironntental Quality-Division of Water Resource. Revised fs.f-n1it •
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