GW1--00807_Well Construction - GW1_20240131

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
William J. Miller '31imm:ERZClr1ES,. , t .N •;_:. Wt ._ F 1
FROM TO DESCRIPTION
Well Contractor Name
ft. fft.2927A
ft. ft. i '
NC Well Contractor Certification Number j ;,p()T)tLFAStSatfotlu( 'elired ielleTti 1NER{ltap,,,gg'''' hlej ;i
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in
Company Name
P Y A y.1rINNER ASING OR'TE AING4Wili kEie"eit4 146bTi w;"-.!.,-. _'
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:N/
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.
Water Supply Well: '�17.SCRE£N��E/<s'�. Rttt., :�,.F€ „-.. x .,.:. , -:,>., ,..�+.�;`..,..�.. "-_.t_ ,...:: :
pp y FROM TO DIAMETER SLOT SIZE THICKNESS _ MATERIAL
Agricultural DMunicipal/Public 3.5 ft. 13.5 ft 1.0 in. 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) leollUU3 1 ,,,,` f„ a" „
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- : 2.5 ft- bent. chips Surface pour
x Monitoring DRecovery ft. ft.
Injection Well: - '
ft. ft
Aquifer Recharge DGroundwater Remediation
51t1SANO/ORAVELTIACIOlfaiiiilielible):'ICAMASMI4FAC=A1.zaglAM
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 2.5 ft. 13.5 ft. #2 Medium Sand Surface pour
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Daracer 20.f1RIL1:IN,G,G4G,.(atiacb'additiohal'sheets i£iecessary)a:'{. _,.a.a'r"'.
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
12/05/2023 SB-3 ft. ft. p;'`•
4.Date Well(s)Completed: Well ID# r '''`}' 't,y n
ft. ft. 4 .
Sa.Well Location: ft. J €Y L`U,L4
Pinnacle N/A ft.
r n
Facility/Owner Name Facility ID#(if applicable) fL ft. lflizi ie..3.;,i.,'7 ; r;-;...�,.;,,,!.;,, ,,_„,
14541 Airport Rd, Laurinburg, NC 28352 ft. ft. DWw:oG ,,,`
Physical Address,City,and Zip ft. ft.
New Hanover N/A ,z1. Iwwrs
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:
34.767388 N -79.373133 W
" " 1/22/24
6.Is(are)the well(s)OPermanent or X Temporary Signature of Certified Weil Contractor Date
By signing this form,1 hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or a 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 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: 13.5 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-3 200'and 2@100') construction to the following:
10.Static water level below top of casing:6.70 (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. ,
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016