GW1--01504_Well Construction - GW1_20240312

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WELL CONSTRUCTION RECORD Far riletnaIUscONLY: ' '
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This fain cart be used for single or multiple wells• •
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. I.Well tontt:Ictar Information: ,
• :IS..WATERZONES '
Robert Miller ._ FROM TO - 'OFSi rnprloN- : ' .
Well Contractor Name- ft. ft. 1
. -ft. ft. -
2675—A •
•NCWc11ConiiucrarCcaifmatioiiNwiiier IS.OUTER casrsG(forttutti-casednensiOR LINER Rfan ticobk7,
• FRONT TO r DIAMETER•+ TRIMNESS, ' MATERIAL
SAEDACCO ' n. ft.. iti.
Compel). - 16.INNER CASING OR TUBING(geothermal dosed-loop). •
. -FRONT TO DDCHEIER. THICKNESS - MATERIAL •
. . 2.Weil Construction Permit 8:m0100767 - --rt. . ft: ,n-
i is1 all nppalierihle well prel iti(Lc.County.S1aae,.lrariarme.L)rK'O 4 rtr,.i
•R: q, in
3.Wc1t:Use(check W Well Use): ItSCREEN •
_ __ . FROM. . To DIAMETER •SLOT SIZE THICKNESS. •MATERIAL
Water Supply Well;
DAgi eultinal ONlunicipal1Public • R• ft. itr .
°Geothermal(IleatingiCooling Supply). DResidentiat Water Supply(stogie) ft.
(� in
ElltrdustriaUConutiercial ®Residential Water Supply(shared) -2a:Gtit]UT
FRONT- TO MATERIAL - EMPLACEMENT METHOD FAMOUNTr
Dki iation ' '. ft. fl.
Hain-Water Supply Well:
°Monitoring.. IJRccovcty • fr.
injection Well:, . . . • tt, tl .
CiAgniferRecharge' EdCitoundwatcrRcntcdialion 19.SAND/GRAVEL PACK of applicable)``
"FROM • •TO - MATERIAL tMPL10EAIENTNtTIIOn - .
. °Aquifer-Storage and Rccovety , i7Salinity Hamer ft.. 0.
. . •. AAquifcrTest : ❑St u nl'aterdrainage I. 1G •
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• ❑E5cpcnmcu1alTcelinotogy . •- IDS ttbsittcnccCotdrul
-10:DRILLING LOG(attach additional sleek if isccessan't
OGeodtennal•(ClosedLoap) OTiacer , FROM- .TO DESCRIPTION reobr.hnnlnci.wlwmektsse.anio.Oe.'&1' '
t7Geotlterival(lleaunglCaoliugRelun)) : Eimer(explain under e2l•RetuaiLs) 'n- it. i r< ' . r%�`''ti.7, ;S ii
• ft. - " ft. 2,.-'14..r IL.".i. s? 1... „
.4.Date WcU(s)Completed; 2/19/2d {Yell iD77A-1 —•A—$
fL • MAR-1. 2 i0?4 .
5a.Well Location: , . (4 it. •
i tt
Former Foothills Service Center -iL ft, n` .:', �„:7,, ad. ni,
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•Faclit)•,'Oisn rNanoc. facility iD#(ifapplicable) - " • '
R. ft.
312 E. Union St., Morganton, NC; 28655 , ft. •• ft.- '
Pkitical'A 14i.0i,City.and Ztp'• '24 REMARKS
Burke
Coauly 'Parcel ldcnlitiieilian No,(PIN}
5b:14.atitude and Longitude in degrecslminutrslsectinds cif decinuil degrees: Cc 22. rtifieatiorn•. .
(ltucllfield,onelattleatlggudlickia) I•' .
N' Wjg4....j _f"32/27/2024
Sigaituieofi':? c'.`e+tiW.r .Date •
. 6.Is.(are)theweIl(s):.OPermanent., .or SlTemporary • Ifisigning thin fowl;f hereby certify that the weil(s)was(totem evcuntcted krrac Iancr '
• With ISA NCAC 92C.0100 or 15,4 NCrtC92C.0200Well Constnerrlo,r Sratutards and thane u
7.IS this a repair to an existing well:. OWN or 'El Nu erjrofMir rtrnrdhasNea p:we/ekd tour urnmcncr. '
ljtbls'is a repair:fill oar iiaoavi well construction loformnrion and aiplahr the more of the .
repair tinderP?1 rmtar1..reiwo oron the bark of ihie fornt. - 23.Site diagram'or additional well details:
You May use ilk.back of this page to protide'additional well sire details or hell
8.Numberof wells constructed: 5 - • construction details. You was'also auacttaddiliotiat pages if necessary.
For mahlpk rrtfecilan arnail-1riuer supply wells ONLY with the same co,nstructlo,r,)aa can - -
sabniita ie fomu. SUBMITTAL INSTUCTIONS •
• 9.Total well,deptlt below land surface: 30 ' . (ft.) 24a. For All Wells: Submit this-faun within 30 days of completion of well
• For mahlple'iivelrhsr oil deprhsifdi.#reiit(erwnpfr-3E-''f1D'arul?r)Ii7O) constflictidis to the following: - -
10.Static water level below top of casing:. (It.) Diiiiton of Water Rtrot%rcc t,Information Processing Unit,
.if tracer lever is above easfilx•u."+" 1617 Alai[Sun icc C`ter,Raleigh;NC 27699;1617 ..
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II.Borehole diameter 1.5" (in.) 24b.For inlectipn Weill ONLY: in addition to sending the form to the address-in
.24a above.also.submit a copy of this foam within 30 days of.completion,of well
12.Well constivction'rethod:DPT • . collstmctitm to the following:
(i.e:auger.'rotary.cable.('itcct rash etc.) - i
. . •Division of Water Resources;Underground Injection Control Program,
• FOR WATER SUPPLY WELLS ONLY: ' . ' 1636MailServiceCenter,Raleigh,NC27699-1636
13;r Yield(Film) • MethodDf pCSt: '24e.Foe'Water Supply&injcetion'Wells:
Also submit one copy of this'font Within 30:daysofeompietionof
136.Disinfection type: _ Amount:, • sell construction to the county hetriilli department of the.county.where
constmctcd. I
.Form GW-L NonhCarolina De sonment of Envit-uanr of and Natural Resources-Divi;lonof Water Rewu'as Revised Attuut2013