GW1--00803_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:
William J. Miller _14.ANATERzoNEsfl..uw,mais .s E_g . =o E i. . ;
We11Con1ractorName FROM TO DESCRIPTION
2927A ft. ft.
•
ft ft.
NC Well Contractor Certification Number i$XtUTER•CASI15`GXformalh Cased;i e%)...0T(U ER{iflii Geable), ``; ;,
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
ft ft to
Company Name �lb:`,iN14E12 Ct�sli icAR FUBII�(r'rEeotlisa iii eteised loeP)a sI' U, .,•_;.'z°' V,
2.Well Construction Permit#: N/!//��1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UJC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
;Iillt SCREEN°... l:..._ ....:...... . : ... .',,=i. t o z H < .; _.... .:
Water.Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 2.5 it 12.5 it 1.0 in' 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
Industrial/Commercial s Residential Water Supply(shared)Y( ) :°I8:CRY3t1T,._amw..x .:: o..,.v.,m-_ _. ,,.,..,... .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 1.5 It bent. chips Surface pour
x Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
:%SANIIIG1 NME ACIC:(irinigkiible) _,_ E .. . a a.... x 04
Aquifer Storage and Recovery OSalinity Barrier FROM • TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 1.5 ft, 12.5 ft #2 Medium Sand Surface pour
Experimental Technology OISubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20 s1 ;ILLIN TAIG"(sfiiichr Coitala DESCRIPTION(color,
hardsary)r-." _. __' ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO
(color,hardness,soi0roek type,grain size,etc.)
ft. ft.
12/05/2023 SB-6 ft. ft.
4.Date Well(s)Completed: Well ID#
5a,Well Location: ft. ft. (i r :,�
Pinnacle N/A ft. ft. • '
tyFacility (ifapplicable) ft. ft. BAN 3 1 2024
Facility/Owner Name ID# a licable
14541 Airport Rd, Laurinburg, NC 28352 ft. ft. inforrri,,-- n ,,r_
Physical Address,City,and Zip ft. ft. t yZ-'Q,'j. `'
New Hanover N/A 21..1tEh1A1t1G5F-, , , . ,,,. i; .._ lgzn, ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification: a-'"'
34.768215 . N -79.374485 W . '"•�
1/22/24
6.Is(are)the well(s)1Permanent or Temporary Signature of Certified Wal�Contractor Date
x
By signing this form,I hereby cert051 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or x No with 1SA 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 421 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: 12.5 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 rtl 00'and 2@I00) construction to the following:
10.Static water level below top of casing:7.07 (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 Injection 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 I Revised 2-22-2016
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