GW1--01509_Well Construction - GW1_20240312

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WELL CONSTRUCTION RECORD
Far-fills mat use ONLY:
This form can be used fat Single as nusltipk wills- '
1.Well Contractor Information: '
'Et WATER ZONIS -
Robert Miller _ • FROM TO DESCRIPTION '
Well Contra lot Nam* ft.. R.
2675-A - • .IL- fL I
_IS OUTER CASING Ifor.-nuhl•rasediscnsl OR LiNER Rf an ticable),
NCNCI1ConlfncforCcrtiftcalloONmFber • 6ROMt To DIAMETER• T WK%iSS MATERIAL•
SAEDACCO • fat. fL ln.
compvey N:1nr6 . ' 16.INNER CASING OR TUBING(geolhrmat dosed-loop). '
•FROM TO DIAMETER TOICIGNESS MATERIAL
. 2,Well Constnietitln Pe1'ibit fi:m0100707 - 'R. • ft: - Ihi.
i allapplicuble welt pei nits,(i:e.Cpunry.•Stane,Variance.)termite)rIc;) t• rt.
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3.Wcll.UsC(checic.w'ell use);- tx SCREEN
_. -._-__ - BROM'. TO . .-DIAMETER SLOT TRICK N INS• I MATPRTAI,
,
Water supply Well; .
• ❑Agricultural . ❑MunicipaUPublic ft. •Its in
ClGeotllcmtal(HeatingiCooling Supply) ®Residential Water Supply(single) •R. fL iuI
OludusmaliContniercinl ®Residential Water Supply(shared) '.tlt:GROU7 =
FROM TO -•MATERIAL , ' EMPLACEMENT NICMOD R AMOUNT
' ❑frripation . •ft. ' • ft,
Non-Water Supply Well:. •
°
. :ft.. _ ' it.' .
- C Monitoring i7 Recovery-
In/ccllon'Welir fr. •ft,
ClAgnifer Recharge f2JGroundwatcr Rcwcdiation -ts.SAN INGRAVE L PACK(if apptkabt)' '
'FROM - TO" MATERIAL EMPLACEMENT METHOD •
CJAilnifcr Stoingc and Recovery ClSalinity Hamer R.. R. •
' l7AgnifcrTcst- - ❑StormmatcrDrdiiagc .ft. ft.
❑Ezperimcntal Tcelmotogy °SubsidenceCont[of 20.DRILLING LOG(attach addltionnl'shcels if accessary,
❑Geotltetival(Closed Loop) ❑Trieer. .snort- TO DESCRIPTION frobr.harNacri.rrtr'nrektsue. n,ve.eu:l
❑Geothermal(Reatiug'Caoliug Return) . ❑atherlexplain wider 2t Relnalks) .rL ft.
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. . 4.patoWeU(s)Conipleicd; 2/19/24 • .wellllltfG-1. G-3 .s G=5 �. r .�.`'`4r i `k: ---; .
5a.Well Lncatfon:' ft.- • f4. • • • MAN 2
2I17.,
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Former Foothills Service Center rt. ' ft. c.__
Factlit;'OivnerName. ' . . . !codify ID#(if leablc) illrr,..,: -.—,�,_—
} m �gFP ft. ,.4an.s 1.:Rx
312 E. Union St., Morganton, NC, 28655 . • . �i``vlsr''��(�
_ R. ft.. •
Phy5icalAddiess.city.pitlZip• '2L.RElt1ARKs. • .
Burke Injected 120 gallons of Cool-Ox per point;
Couch Parcel tdcutifi tionNo.(PIN 15-30' • I
.
Sli.Latitude and I.wngituile in dcgreesiminutcs/scconds or decimal degrees: .22,eh:tuttcatlnn, i
druid'1•seld,onOalliong ls`Stdiielcid) I •
,
i.• ��01 2/27/2624
SigroWraf*.,t.a.e0-ir': sS;:i:r.�'�''�•-- Dale
. 6.is(are)the well(s): ❑Pertnanent. or .16Temporar}' 1);3igning thir.fatmr'1 irereb}•iertify thrall.lu in c/I(s)KW(purr.)co:am cted in amonlmur
Wilt 15A NCAC 02C.0100 or.15A NCAL'02C:0200 Wei!Coiisrrrietiae Swadards and china
7.Is this a repair to an existing well: ❑Yes or tQND catir`of rhiT record h'as Bien arneidcr!roOr rirll moles
Ifibis"is a repair;fill oat bairn will constnrctloa Inforraa li t acid cspiabt the ivamre of the
repair rimlerdi2l ienatrksseciian pi-on she back of this-tacit. 23.Site diagram or additional well details:
You may use tiie.back of this page to provide additional sell site details or well
8.Nnmberof walls constricted: 3 construction details. You may also attach additional pages if necessary. •
FormhlxipielrmJecilonsiram-watersxppiitwellsONLYwiththesameconsirrtrtion,youcan i -
.submitoneforoi. ' SIiRMITTALfNSTITCTJONS
9.Total wclldepth betowlandsurface: 3U t:e.) ,24a. For All Wells: 'Submit this form within 30 days of completion of Well
For mrilrlplawe/klisrall depths if dif"rrem(example 3€,00•and..2 100) construction to the following: '
10.Static water level heluw top of casing: '(it) DiViiiiion of Water Resources,Information Processing Unit,
if wirer level isithove'tnsfax asa'4'• . 1617 Mail Service Ce.nter,Raleigh,NC 276994617
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11.Bore moic diauicter:1.5" . . (In.) 24b.For Infection Wells ONLY: In addition to sending the fomr to the address-in
24p above.also submit a,copy of tbis,.fontt within 30 days-of completion of mil
12.Well constcnctfon"method:DPT constmction to the following:
(ic:auger.'rattly.cable dined gash etc.} -
• . . 'Division of Water Resources,Underground injection-Control Program,
FOR WATER SUPPLY WELLS ONLY: - - -1636 Mail Service Cent Ir.Raleigh.NC 27699-1636
f3a,Yidi1(gpm) Methodoftest; - •24c.For Water SnpL Jac IJection%WI1v:
Also submit one copy of this fomt'Within 30-day'sofcolupletionof
13h.Disinfection hpe: - Amount: . . - - - well construction to the county itcalthi department or tfuc.counly.whcrc
. - . -. _ constntcted.
Form GW.l Ninth Cmolinu Ocpannncnl of Enrimnnrru mid Nanusl Resources-Division°Mai r RRnrr - Ri iscd August 2013