GW1--01507_Well Construction - GW1_20240312

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WELL CONSTRUCTION'RECORD Poi IntcntalusoONLY: I '
This form can be m used for single or ullipk wells 3
1.Wcli Contractor Inforivatiou: . •
=t1.,WATERZON IS
Robert Miller • .. . . FROM - TO ' DESCRIPTION• I .
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WellCormngorNamo, ft, ft,
2675-A ft. ft-.
NC Well Contmclor Cori iftcationMother • ' ' .IS OUTER CASiNG(for cant wised sseflsl OR LINER(If ap Hain '
FROM TO - DIAMT,,TF.R-1 TRtCKNTiSS• MATERIAL-
SAEDACCO . ,fL - ft` In.
Compare?Nam I6.INNER CASING OR TUBING(saatturmal closed-loop); .
.FROM TO- • DIAMETER THICKNESS' - MATERIAL
2,'Wcll Constt'uctton Permit f):m0100707 R. • . it: n: '
list all well permits(cc.Cow,,.•Slide;•Varta:ay.h}ratYan etc./.
•R:: rt. to.
3,Welf:Use(check Well uce): 17.SCREEN
-- - -" ---- -_Water Supply'Welk FROM'. . TO tfl%METER •SLOT SPX THICKNESSMATERIAL
❑Agticulitiral . .' OlNu c'micipal7Publi R. •ft; in
I�Geottiemtal(ueating'Cooliog Supply) ®Residential Water Supply(single) ft. ft., iu - .
CI Industria1lContotercial ®Residential WaterSuppl}'(sbatvd) -ts GROUT ,•
FR051 TQ . -MATERIAL , EMPLtCEMENTMETHOD,& Ni'AMot
. . ❑htif ation . - ft.. ft . '
Hon-VYatcr Supply Well: .
121�9onitoring . . .❑Recinety. ft. R. .
Injection Well: . , • - • ft.. .rt. •
C lAquifer Recharge Elfliaundivater Rentediation- -,t9.SANDIGRAVEL PACK Of spin irabM '
' 'FROM-- TO' • MATRRLtt. , • • F.\IPI. T.'.ENT NITDOn
OAgnifcr-Stonrgc and Recovery .ElSalinity&amci - -rt. R,
❑Aquifer Test - ❑Slommatcr Dntinagc' R. D.
' ❑Experimental Teciinotog}' . C]Sulisidow Control - •-
10:DRILLING LOG(mach additional sorrels if ivreessurvi
❑ge0tllennal(Clased Loop) ' . . ❑Trice[. mom• TQ DESCRIPTION(cob[..haMdcN.wtEnecktr#.pmio,nnHtl '
❑Geotltcnual(Heating/tooling Retunl) t7011►er le cpluuLtnnder#21 Retuodts) =ft. iI . • j � .�' :-.•L 'f ;1 -:o
- ,a ;..r-V ¢ -1 ft.. ft � , - s 4.Date W*ll(s)Compictcd:'2/19/24 Veit m#E-1 - E-5,
R. . iL MAN.12 2074
5a,Well Location: ft. IL •
Former Foothills Service Center • it. f. tG'� "� "� '�` """` ' v'tJfi '
Facilit}•lTivrnrNnme. • Facility IDk rfapplicable) • Li'rC1''':''�(=
• R. , ft.
312 E. Union St., Morganton, NC, 28655 . •R, ft.:
Physical Address City-and Zip ,.21.REM1LiRK.S'
Burke . . Injected 120 gallons of Cool-Ox per point;
County heel itietliifteatiuiuNo,(PIN) 15-30'
51i.i atitotle'arid Longitude in itegrecslminutcstscconds or decimal decrees: 22.Certification:•
' (Its eit weld,one tatrlong is's dfttl nI)
.N W. 2/27/2024
SigmWlrafc,,.c;.c�Xt3;es-,v?s..ce::Y �''~--- t}d9c
6.Is(are)theweli(s): ❑Permanent: or SlTemporat}' •Upsignntg ihis form,1 kcrebr certify that she,veilfs)my Owe)eanrimrrrd br.anorr/once
• with 15A NCAC 02C.0107 or 15rt NCAC-O.0.0200 Well Construction Standards and thora
• I,Is this a repair to an cxiNtin„ricfi: Oiler. or IBM, • copy of Mir record bus&enpnn'hkd torte‘all owner,. •
lfrhls'is a ivy's.:fill artkaanv,wiAconsmrctlaa injormarion and riplaln the onwee oldie
rept:arwrdcr 821 remarks 3ecriau or an the bark of ihlr jornr. 23.Site diagramor.additional well details
You may use the had;of this page to provide additional well site details or welt
8.Noniberof wells constructed: 5 - - construction details. You may also attach udditionalpages if lecessaty.
Far auttedple rri(ectlon or non-water supply wells ONLY with the=deconstruction,,you con '
submirone form. -' SUBAMLTTAL iNSTIJCTIONS •
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9.Total well depth below land surface: 30 ow 24ii. Fur AU Wills: Suhniit ibis form within 30 days of completion of well
For mo_lalpleirells'list all ATMs ifdifrirnt(e.rarnak-3@201'and2tSWO) ' conslnictionto the foltoning; I • -
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10.Static water level below tap of casing:. -DO Dii•isiun of Water Resources,Information Processin„Unit,
!Prater level Is abate caehi:ase"k" • '1617 51ai1-Ser ice emeier,Raicigh NC 27699-1617
IL Borelsolediautcter:1.5" . (fn.) 24b.For injection Wel'ONLY: In addition to sending the fool to theaddress:in
24a above.also,submit a.copy of this form within 30 da}ys-of completion:of well
12.Well 61111 teuctioa'method:DPT . . coitslnic(loo to the following: I
(i c:auger.rotas}•.Cable.direct paste etc.) I.
'Division of Water Resources,Underground Injection Control Progratu;
-FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Center;Raleigh,NC 27699.1636
13 r,Yield(gprn) • �ictlrod'af test 24c.For Water Supply its Nation Wells:
Also submit one copy'of this faint Within 30 day'sof completion of
I3h.Disinfection type: Amount: well construction to the county health department of the.con nh•.whcre
_ - - - " constntcted,
Form.GW.L Nonh Caraltna 1lepauthetti of Eui'irorutrtu aid Natural Resources—Divivloo of Noicr Recoucm. Revised Attgust2o I3
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