GW1--00808_Well Construction - GW1_20240131

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
William J. Miller .ia:.:�AI : K$. ...I,xi. =;t. <a.. . . _.._.. _ .M.._m,.. . .g 3-
FROM TO DESCRIPTION
Well Contractor Name
2927A ft. ft.
ft. ft.
!
NC Well Contractor Certification Number lKtiej'Eg, $ING.(fora itOr•za5ed e1,E )'()R'C;lt!IERtifit�1`jtca6lel.#`' t r
CATLIN Engineers and Scientists FROM TO DIAMETER! THICKNESS _I MATERIAL
ft ft. 'in.
Company Name t EI
1&:1tVNERiCitS1Nt)1t TII611�(;(�esfl`errival:clgaed-loop).,..�.�ra..,<>:_F..4_rt..��.,�;,
2.Well Construction Permit#:NIA 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.
I4,7 11EEN., s; m s t n°
Water Su 1 Well: t.,. ..> 3 F,,.., 3 L, , S
pp y FROM TO DIAMETER SLOT SIZE M THICKNESS MATERIAL__...
Agricultural DMunicipa1/Public 4.5 ft 14.5 ft. 1.0 in- ,0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
Industrial/Commercial QIResidential Water Supply(shared) AsvogottraewiminpmoMimialaW;WWINErlgttlKUEMOVMV
Irrigation FROM TOMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 3.5 ft bent. chips Surface pour
x;Monitoring ORecovery ft ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation sgA$1N „> ,.
£ ;1 1.VELPACI((alnpphcatite). ...< i. a E x,3 ig ..:}c .
Aquifer Storage and Recovery E3Salinity Barrier FROM , TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage .3.5 ft 14.5 ft. #2 Medium Sand Surface pour
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .26DifTL'Is"iNG.L3G.(atrach`adthhoualsheets,tfuecessary)w;z ..N. ,s ,=
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)Y
ft. ft.
4.Date Well(s)Completed:12/05/2023 Well ID#SB-1 ft. ft. '1-7:;":'` ^,F- `
5a.Well Location: ft. ft. -'' '..re(1,..„ r" yda�2''�1. 1
Pinnacle N/A ft. ft. BAN 3 r 2O24
Facility/Owner Name Facility ID#(if applicable) ft. ft. in ter .`
14541 Airport Rd, Laurinburg, NC 28352 ft. ft ' (y 'fit^:Kiir'r Le
Physical Address,City,and Zip y ft. ft.
New Hanover N/A �p���A f m ,,i
.�Ls�fl+'.Afsll ,.�3 r � ,,, ;,f .a>.a.�L.,zE ,... '�` :-F- K ..?M4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Mt/long is sufficient) 22.Certification:
34.770864 -79.372507
�,=�"`�`"='' 1/22/24
,P
6.Is(are)the wells) Permanent or [3 Temporary Signature of Certified Wall Contractor Date
By signing this form,1 hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or oNo 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*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 I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14.5 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths tf different(example-3@200'and 2 tt 100') construction to the following:
10.Static water level below top of casing:1 1.0 (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 td the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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