GW1--01343_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD Fix lrscrml Use ONLY:
This fann can be used foi single&multiple netts•
1.Well Contractor Infoiwation:
..LIAVATERZONES l .
Robert Miller FROM TO DESCRIP110Y -
Well Cotxngor.Name - rt. ft. I '
2675-A ft. rt.
NC:WellCon1r�ctorCoAificationNruibcr .15.OUTER CASING(formulll.aa dssetls)`ORLlNERtitai ficabk)
FROM TO DIAMETER.-' THICKNESS MATERIAL
SAEDACCO ft. R. ia.
Company Name- '16.:INNER"CASING OR TUBING(geothermal closed-loan) •
• FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:WI03000514 -(1. ft, "dd
I st all apptlirjtble writ prueits(i e.Caunty.Static,V priance.Lfetr of etr.:)
•ft. ft. in,,. .
• 3.Well Use(check-Well uscj: to SCREEN
Water Supply Well: • FROM. " TO DIAMETER 5r,0T'mir,E THICKNI S 1 MATERIAL •
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°Agricultural • ClIMlunicipal/Pttblic R. ft: in
BGeotlretmal(HeatingiCooliug Supply) ®Residential Water Supply(single) R' fL' In I
®LnduslriallComnte vial . CIResidential Water Supply(shared) boo ROUT TO . ' •MATERLW EMPLACEMENITNIETHOD CAMOUNT
Etktipation rt. - ft.
Non-Writer Supply Weill . . '
13,Monitoring l7Recovcty. - . - R. n
Injection Well: - .ft. •ft. .
®AgnifcrRccltargc RtGioundwatcrRcmcdiatton 't9=SANbIGRAVEL PACK(if nil plkahte)-
'FRO\r TO' • M,tTT:RIM RHPI„K:E\rEVTV row n '
OAgaifcr.Storagc and Recently 17Salinity Barrier. R..- ft.
0AgtiifcrTcst. ElS ormnatcrI'Drain* . ft. •it, .
QEylctimctl(tI Tcehna(Ogy °Subsidence COMru1 •20:DRILUNG LOG(sitlacb-eddltional-Sheets it ncccssarel •
DGeothennal(Closed Loop) - '°Tracer .FROM TO - DESCRIPTION(cobr.haroacr+.ran'mrltgrc.tra+a site.de.)
1:Geotlrem:al(Heating(CaolineReturn) ❑Otker(explain under#21Remarks) 'ft' rt. - .
ft. ft.
4. well IDitc-1 C-6
It. ft P:k a'"..4 -_ ''� -...
So.Well Locating .rL• rt . c L E t�
• Former Rudisill's -66 r4 ft, , MAN 0 4. 2024
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Fas_ility/Ois•rrrNamc Reny)D#(ifaFplicable) R. It.-
2707 1st Ave., Hickory, NC, 28602 R. R,•
I' fniorJra:•k,-1?'r �. V>4 '
Dina,..3 4
Pity siaat Address.City.and Zip ,2 C.REItIARKS '
Catawba Injected 208 gallons of Cool-Ox per boring;
Comity t'arsd Iskelitca11ou Na.(PIN) • 1 9-35'
5h.T ttitiidc aril 1.ongitude in dcgrces/minuti tscconds or dccitiial th.gr 1aa. 22,Certification: I.
Owen fend,OW.1:4tlant it a'rdIi51ird)• '
N W n,. ..„,-,)„1..!.„, 2/2
�j� 7/2024
Sigaiwteof�'::(..i ,rs•.-;:�r. --- Dam
6.IS.(are)t11e.{{'ell(s):.❑Permatletit .or 10Temporat' •11fsigning rhir fanr,'1lrereby terrify ihru 0ir nellis)was Owe)crmrrnrcred in accordan. ce
with 15A NCAC 02C,01(70 or 154 NCAC:02C.0200 Hid)Constn rrkn Srandards and that a
7.Ls this a repair to an existing well: °Yes or ➢LINO ropy of this record has 1i,cn provident to the well moter. -
if'this Is it repair.'fill mrrr 70.61 1ST il cowl uctioa brfornunlon and explain the turmre of the -
repair w-derO21 remarks3caian or cm the back of this•form. • .23.Site diagram or additional well details:
You may use die back of this page.to.provide additional well site details or.Well -
S:Numberof wells constructed: 6 eoustructiatt details. You-May also attach additional pages if necessary. -
For maple Infection or aoa-,inter supply wills ONLY with rlir'same canstrueriou,you tart S III:MITTAL INSTUI 7 IONS•. • •
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sabnuraneform.
9.Total well.depth below land surface: 35 . (n,) 21a. For All Welts; Submit this-fortn within 30 days of'completion of well
For multiple wells list all tdrpths ifdl,Uere a;(example-30200'and.20'lOt) construction to the following:
10.Static water level below top of casing: - .((1,) Division of Water Resources,Infttrnuttion Pm cessin;Unit,
Ifwaer level Iv above casfo;;ale"+" . . 'I617MAU Service tenter,Raleig,NC2 7 699-16 17 .
11,Borehole diameter:l•5„ (iu,) 2-lb.Fnrfiilectian Wells ONLY: In addition to sending the faint to the address-in
24aabov'e,also.submit a copy of this.font]within 30 days of completion of well
12.Well constcnction'method:DPT construction to the following: '
'(lc:auger.meaty,cable,direct past[etc.) - F
Dis'ision of Water Resources;Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: - - .1636 Malt Service Center.Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 22•l.For Water Sun&rh'..'itInLcetlan Wells:
Also submit on`copy of this form.Within 30•days of completion of
131,.Disinfection hype: • • - Amaunt: well construction to the cotmly health!department of the.county.where
constructed.
Fonn,GW-1 Nortlr Carolina Depcu hentofErnirmuuctualitNanualResources-Divirlonof WaterResothoes. Revised August lull
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