GW1--00802_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
William J. Miller iil4We1TER'ZO1 SA,._<.;\` a.V ,,... n " M.W: ,t...
Well Contractor Name FROM TO DESCRIPTION
ft. f
2927A t
ft. ft. I
NC Well Contractor Certification Number
35(3tUTZA CAS NG461'nt cased wetis).OR`i I;R(ifii-'eahle} s s .F<. .;
CATLIN Engineers and Scientists FROM TO DIAMETER ' THICKNESS ll MATERIAL
ft. ft. in,
Company Name
,�16 1 R'GASINO QR ATBIN,r f ittliieiMatift d t1innY `E .t .
2.Well Construction Permit#:N/"A- FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
x Rr
Water Supply Well: FROM TO £ DIAMETER t SLOT SIZE THICKNESS pit MATERIAL "
Agricultural 13Municipal/Public 0 ft 10.0 ft• 1.0 'n' 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) f,, ft. in.
Industrial/Commercial DResidential Water Supply(shared)Y( ) .`I8.>G1201IT<r.3x 3'`. .�"...N�`,`.°. .....mi 3 i :`..> . `„.<„„ s:.„. si.':
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 1 ft.
x!Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
I9IA fD/GRaYY.EII-1BACKfirinpli6all'e).._, i.::....,
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 1 ft. 10.0 fr• #2 Medium Sand Surface pour
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ,2(l%1?RILLING=[OC(attncliaddtb"on`af;slte"ets;f" nary), ,'> -•. --
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROMTo DESCRIPTION(color,
hardness soil/rock type,grain six,etc.)
ft. ft.
4.Date Well(s)Completed:12/06/2023 Well ID#SB-7 ft. ft. r'-,.
6
5a.Well Location: ft. ft. �:b,q l_,h.=:, - •,-
Pinnacle N/A ft. ft.
'A t�j ,'',
Facility/Owner Name Facility IDkft. ft. ZG(ifapplicable) 24
14541 Airport Rd, Laurinburg, NC 28352 ft. ft. to Jrrr;.; _,�,r'-
Physical Address,City,and Zip ft. ft. 11Ysiu• jL74y""u LIS'(
New Hanover N/A .21sREMARTL+i<. , t ux E ;,.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ,/r,,-r'..
34.769176 N -79.375838 W t---, '" 1/22/24
6.Is(are)the well(s) Permanent or xITemporary Signature of Certified WLtf Contractor Date
By signing this form,I hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or x No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 621 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:8 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10'0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dif/hrent(example-3 tt 00'and 2@100') construction to the following:
10.Static water level below top of casing:3.00 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Direct Push above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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