GW1--00805_Well Construction - GW1_20240131

EVATErA7+ ;I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
William J. Miller 4'44WATERZONEVFWVITAAMAMMAgZ2MVIIVEMUMN1SIMUM
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2927A
ft. ft. ` �
I
NC Well Contractor Certification Number
Vt5:ailTERLh.Sint:(foi=mvlhcased.welliWR<LINERfifap" Lle) ..: ...,14
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
ft ft. i'in
Company Name A ;T6 INNER.UASI +1;c9C RITVBING(KeoYl er a ahatiied.lootO ,:: x iAgi ,.,•ii
2.Well Construction Permit#:N/" FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well rn$cItEElt tb ,. '.. -.. £> . #..��`._?.._- _ . rx..FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL-re4€
Agricultural DMunicipal/Public 3.25 ft. 13.25ft• 1.0 in. 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
38i G1tOT11' ;. a s '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 2.25 ft• bent. chips Surface pour
x Monitoring 0Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation V If.,SAN�G , E.LA�CI{B apfrlieiibte}
Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage 2.25 ft. 13.25 ft. #2 Medium Sand Surface pour
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer s2f#DRILLINGL(k tattuchsddAbonlrll eisl,f sary}.,mb ka ,, ,. F.... ;
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed:12/05/2023 Well ID#SB-5 ft. ft. i
5a.Well Location: ft. ft. `•� ' 'il��i `y 't,^r s
Pinnacle N/A ft. ft. JAN 3 1 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
14541 Airport Rd, Laurinburg, NC 28352 ft. ft. :,3.,,...„_ ,n :-,--
Physical Address,City,and Zip
ft. ft. _ t,,:, ;..k.
New Hanover N/A x:" , a:;shn s> >.n..x,w. .3 N 3 =t.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.768574 N -79.374477 W
---,�. �:--• �
,:%` 1/22/24
6.Is(are)the well(s)DPermanent or (:)Temporary Signature of Certified.M ell Contractor Date
By signing this form,I hereby cent&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: LJYes or 1:2 No with 1SA NCAC 02C.0100 or 1SA 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 21 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: 13.25 ft.
( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifderent(example-3Q200'and 2 a 100') construction to the following:
10.Static water level below top10.60
of casing: (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&Iniection 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