GW1--01340_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD For Internal Usc ONLY:
This Comeau be used for single or multipk wells•
1.Well Cnutretetor Information:
•11.WATER ZONES"
• Robert Miller . - - FROST .TO DF.SCRIPiION
Well Comrtautor Nino, R. ft. I
2675-A ' rt. tt. I. I
NC Well altimeter Certification Nutbet -tS.Otf1't?RCASiNGthieotulp.casedriels)'O&L/NL'Rdraf Hea6tel: •
. . . FROM .TO DIAMETER THCKNESS• MATERIAL.
SAEDACCO f. (A. : in.. •
Company Mime :t6.INNER"CASING OR-TUBING(1eatberritat Erased-loop)" • •
-FROM s TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit 4:w103000514 ft. . ft: - j'ba
Litt all npplirable wall permits,(cr.County.State.•Varteuree.Info ft.41r..J
R, . ft. • tn.
3.Well:Use(check well use): 17.SCREEN.
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Water Supply Well: - FROM. TO . tanntE.TER SLOTSIZE TIIICKNI S I.MATERIAL
.❑tlgticultufal ❑htunicip liPteblic R. ft; IL
❑Qeothem l(Heatingt'Cooling Supply) ®Residential WaterSupply(single) R. rt in • I
®hidusirial/Conuttercial ©Residential Water Supply(sunned) FROM TO •MATERIAL . EMPLACEMENT SiCIIIOD.0 AMMOUNT
❑lriipntion . . 'ft.. ' it. •
Nog-Water Supply'Well:: .
fr. • ft. '
• t]Monitoring . IRccoycry. .
Itjecllon•Wert: . R. ft.
0 Aquifer'Recharge fddioundivaicrRcnicdiatiur I9.SANDIGRAVELPACKliravidleatrtci
'MOM' • TO - - MATERIALESIPLtCE EMPLACEMENT SIMROD
IJAgttifcr-Startgc and Recovery • ElSalinity Ranierft. ft.
❑AgriifcrTest ElSlommaterDrtina : ft. • ff. . .
❑>:ropclirncntal Tcclinotogp_ 17Srtbsidcnec CorIttD1 20:DRILLING LOG(attach additional stieetd if taisan•l
• DQeoilieruial(Closed Loop) OTrdcer .FROM• TO - DESCRIPTION rmbr.baronet+.ea:Voi ancr-Fea»r.iri.Hr:I
❑G:othettual(HeatiinelCaoling Return) . ❑Other(explain under#2l Retuails) :ft. ft.
r�. - _.- a.� t .
2/14/24' D-1 - D-6 f6. ft t {�. r L i.�r'h.k_�
• •t.Date Wigs)completed: Well iDtt '
sa.Well Location: . :iL It. . . MAID 0 4 2024
•. Former Rudisill's 66 ft, ,ff. �r
'IriaQriwittc^1 t Pt:Y'.9§l URV.
FaclitylOt urName. Facility IDN,fiegplimble) R; • fA QANQ% d
2707. 1st Ave., Hickory, NC, 28602 tt, • ft.: '
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Plnsical Address.City.and Zip '.21.REMARKS •
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Catawba Injected 208 gallons of Cool-Ox per boring;
• •
County I!arcel IdentiIcationNo.(PD2) 9-35' ;
Sb.j,ittitirdcand Longitude hi degrccs/minu tcslscconds ur dccitnal degrees: 22,Ccrtifieation::
•
(lf rspll field,OtrC I ttlloeig It&ediiticirt)
N W ®�
2/27/2024
Signature af.:rg..P..-0:efeyer.-: —.•:r -- Pale
6.is(are)the weli(s):.❑Pennattcnt or %ITemporat}' •Hy signing tleer bond lrerrbp certify that 114'nzlifs•l wets lwrtrf car.,rtnrcted la accanlance
with 15A NCAC 02C.0100 or 154 NCAC C2C.0200 Well Constrteriorr Srarxkatds and that a
7.Is this a repair to an eristiug well: 17Yei or ZiNo capyof this retort!has Nen provided rerun urll anther.
if this'll is repair:fill am knoaai well coasmellaa.brfornutlon and a plobt the snore of the
•repair wader,'1 remarks-Swain di-rm the bark of dais fornc . 23.Site dials am or additional well details:
You may use the bael:of this page to provide additional well site details or welt
' S.Number of wells constricted: 6 . ' cotistiuetioti.details, You may also attach additional pages if necessary. .
For maltiple lrtfeetlon or nett-tearer srrppli wells ONLY n'lrh Me sareieconsrrurtiotr,vast eon
submit one fans. SIIDMITTALiNSTtICTIONS I.
9.Total well.depth below Irtnd surface 35 (01.) 2.la Fur all Wells:.-Submit this•fond within 30 days of completion of well
Formnhlple wells list all depths If decent(example-3,2 200•and 2e10O) construction to the following; , ,
10.Static water level below mp of casing: • ({l.) Division of Water Resoarce'l,Information Processing Unit,
if water level ly above casing:use'+" 1617Mail Service Center,Raleigh,NC 27699-1617
11.Dorcliotedianictcr:1.5" (in,) tab.Fri'Infection Wells ONLY: In addition•to sending the form to the.address.in
24a above,also submit a copy of this;long within 30 days of completion of well
12.Well consintction Method:DPT construction to the following: fi
(Le.auger.rotary,cable"direct Fish etc.)
'Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13 t Yield2da•For Water Supply&Injection Wells:
(Spm) h(ctirad oftcst: Also submit one copy of this faun'Within 30 daysofcornpletionof
• 13h.Disinfection hpe: amount: wctl construction to the county health1depanmcnt of the counh.wirero
constricted.
Font GW-L Noah Carolina Deparlloent of Enetromoonr and Natural Resources-Divi;ion of WarcrReauooI . Revised August'NB
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