GW1--03192_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD(GW-I) Fur Internal Use Only: ,
Well Contractor Inc rmation:
11� Q ,7 C € 1le.M'ATER ZONES
_ tCl FROM TO DESCRIPTION
ell Con clot N C 1/,O ft. �1({j ft. e Liz,• s
L03-A d``t ft. Dt
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LINER(If ap livable)
MILLER WELL DRILLING FROM TO DIA%IETEN THICKNESS >,.%TEKIAL
ft ft. in.
Company Name 4 16.1NNER CASING OR TUBING(geothermal closed-loop)
1.Well Construction Permit#: — 1 1 FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable sal!construction permits(i.e.UIC.County.State.Variant e.en.) it. ft. in. •
3.Well Use(check well use): it. ft. in.
17.SCREE\
Water Supply W ell: FROM tO IMAMS MR SLOT SILL THICKNESS MATERIAL
DAgrictdtural =Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) 7-Residential Water Supply(singlet ft. ft. in. .
❑Industrial'Commercial EYResidential Water Supply(shared) iti.GROUT
❑irrigation CWells`I00,000 GPO FRO%1 TO MATERIAL EMPLACEMENT METHOD&A%IOC NT
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery it. ft.
Injection Well: ft. ft.
°Aquifer Recharge _Groundwater Remediation
119.SAND/GRAVEL PACK(if applicable) •
❑Aquifer Storage and Recovery 7 Salinity Barrier FROM TO %TATERIAI. F.MPL.ACF.MF.NT METHOD
OAquifcrTest =StonnwuterDrainage ft. ft.
❑Experimental Technology :'Subsidence Control ft. It.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if oecessen)
FROM TO DESCRIPTION(color.hardness.soltrock n train•ire.etc.)
❑Geothermal(Heating/Cooling Return) -other(explain under fi22I Remarks) ripe.
! /( flit') ff' ��C f`' (-)�¢� A ra:n� r
4.Date Wells)Complet ���Well ID# ft. rt. i"
ft. ft.
F I ' Z. ;i...i it ' '1
5a.Well Location:
QV` rlann�oerr1 — ft. ft. MAY 'L i. 2024
acilityy.OwnerNalme r F-acilit(y�11)�(ifappliubk) ft. 1't.
- i� '!'^`l 4 Cl F.1�1ez)q e L.�!\ L o,yesu i. ft. ft. Irk:: ..z..I.: :a 0 �y J' )1
Physi I Address,City.and Zip ft. ft.
��` i$C)70i45-538S 21.REMARKS
County ( arrel identification No.i PIN) tl C s \�. C1 d Q Q T e.l irt✓`-s t t e a -%
((((//// c ro,f►.�f I&) i-c,2�
5b.Latitude and longitude in degrees/minuteslseconds ordecimal degrees: - Ni.�� b0
(if well field,one lai/kng is sufficient; 22.Certification:
6.is(are)the wells): ermanent or ❑Temporary Signnure oo 'ertilicd Well Contractor Date
Hy ngning this lore.!hereby eu'ri/r that the=re•llly M2f i t rry constructed in accordance wan
7.Is this a repair to an existing well: BY'es or eiNo /5.i A'GIC CC.0!00in.154 VCACO2( 0200 Well Construction Standards and that a cape
If this is a repair.f!!alit Anawn well construction irtfnrmdtirn and explain the nature of the of this record has keen prat tded to the well owner.
repair under n2/remarks section or on the hack of this form.
23.Site diagram or additional well details:
X.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 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: -, )t c 0
For multiple celk Ric(all depthc ifdi//rrrnt(example-3!gQ/Xl'and 2!a/M)') (ft.) Submit this GW-1 within 30 days of well completion per the following:
below top of casing: a 24a. For All Wells: Original form to Division of Water Resoerees (DWR).
10.Static water level
below eL• o "'D ( ) Information Processing Unit.1617 MSC.Raleigh.NC 27699-1617
24b.For Injection Wells:Copy to MAR..Underground Injection Control(fUC)
11.Borehole diameter: (Q (in.)
n Program. 1636 MSC.Raleigh.NC 27699-1636
12.Well construction method: &C �C/
( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary,cable,direct push,crc.). county enviro:smental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR.CCPC UA
{ Permit Program.161 1 MSC.Raleigh.NC 27699-16:I 13a.Yield(gpm) 5 Method of test: 1{,•�
13b.Disinfection type: Amount.v
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised a-(.2015