GW1--01511_Well Construction - GW1_20240312

WELL CONSTRUCTION RECORD For l,icrnaltlscONLY:
This form can be ased for single or nndtipl wells I
1.Well Contractor Information:
If.WATER ZONES`
Robert Miller - - FROM • TO • - DESCRIPiION I -
Wclt Col-Valor Namc. R. ft.
267S-A . ft. R; I• •
NC WcWI ConiracldrCcnificetiof Ntu het • IS OUTER CASING ffbr nithkSsrd trells)'OR LiNER(If oil arable)•
FROM lO DIAMETER. " THICKNESS. . MATERIAL
SAEDACCO ftt. ft. is:
Poolsiny Name, Id.INNER CASING OR TUBING(geothermal closedaoop).` '
• •FROM TO DLAMETRR THICKNESS MATERIAL
2.Weil Construction Psrmit#:WI0100707 ft. . ft.- 'P,
till all applicable well permits fie.Comp;Stare,.t+ariart e.Nadal err:)'
• •R: ft. • in
3.Wc1t.Usc(check Well Use).: • 17:SCREEN
• -- _--- FROM. . TO -DIAMIETFR .SLOT Sin: THICKNESS. I MATERIALivaicr Supply Weil: -
•• ClAgitcultutal CMunieipai/Pub)ic R. R' in
[Geothermal(fleatinglCooling Supply) OResidential Water Supply(single) R. I 2, ire I '
.Dlndusirial/Comntcrcial . OResidential lYater'Supply(sliandj . •ta:GROITT "
tiRO'H TO MATERIAL—.
EMPLACEMENT METHOD SAMOUNT
•
Hon-Water Supply.Well::. .
DMoniteding _ .ORecovely R,, ft.'
. Injection Welt: rt.. n•
DAquifcrRcchargc tCJroundivatcrRcntcdiation • L9:SAND!GRAVEE.PACK(if atrplicanti.l".
FROM •• TO' -- Iran:nut. emu A TiII TMr:rann
1]AquifcrStoragc and Rccovety !]Salinity l3amcr. R.. ft. •
l7AquifciTest DStortrmiatetMainagc ft. ft.
•
l7Rxpctimcnhtl T�hnoiosv (]Srtbsidcttcc"CotrtiDl Ii,pftILUNt LOG(Mack additional stied;linccccsarvl
• OGeodrenoal(Closed Loop) I:7Trdcer. .FROST TO DESCRIPTION rcubr.hanlnee;wirnickt gis sim.rk:1
OGeothettnal(Heating/Cooling Return) Miter(e•cplait under al Rettiatls) .. :R• ft.. _
. it: fL -1. y a t:d 3 E _d
4.Date Well(s)Completed:'2/19/24 .We'llID#G-1 .-• G-5 ,t
fL f4
. 5a.Well Location: .ft. a. MAR 1..2 2024'
•. . . n,• It, m;v,rT7it;.^.il: ,..... .b::-F-t •
Former Foothills Service-Center 7r.,,.2.
FacilitllTh-ncrNnme : Facility iD#( applicable) . . vv F�'
R. • ft.
•
312 E. Union St., Morganton, NC, 28655 . it. H.. +
PIryticidAddirss.City.aial Zip' .21.REMARKS - -
Burke •
Injected 120 gallons of Cool-Ox per point;
COnWy l irccl tdenlifcalioo No.(PIN) 15-30'
56.L akin:deatiil Longitude to dcgrvcs/minutes/seconds or decimal gr ccs: 22.Crxtiliicatinu•
(•if4s'ellIiId,Otrd,Lattionnis$fIletcul) I '
•
. N W 2/27/2024
. Sigaatarofi.':::c':4't;�rr s,..:(1;�•�/''--- ' .Dale
6.Is(are)the nell(S):,.❑Petnttanent: .or XITetnporat}' •
llysigning rhir Jana;•1 hereby rernfv thin for yell{.sl vvs()wry)crmwrucred hr accordance
with 15A NCAC 02C.01(10 or 15A NCAC 02C.0200 Well Coitstnicrfolt Srardards and the;
7.is this a repair to an,exittiag well: Dyer or !No coprof Oh reerrdlias nice proridrd rathr Aril mrnrr
Ifthls'is a repair.fill aukrroun.Well conutnrcrfnn brfarmarion and rtplaht the nawre of the '
repair rardcrP21&mark 1 irclimrorasthe bad'of this form. 23.SitediagramoradditionalNelldetail.4: •
-You may use the,hack of this pagel to.provide additional well site details or Weil
8.Numlieraf wells constnicted: 5 coustmctiotideails. You may also attach additional pages if necessary.
For rnaltip(e Weirton or non-parer sirppis wells ONLY with die same roastrartion,yoir eaa '
sahiit'oneform. . - $i1DMIrrALiNSTUCTIONS i -
9.Total well depth below land surfoee: 30 ((t•) •24a. For All Wells:•Submit this faro[Within 30 days.of completion of.Well •
Far mnlripldirnllr'lisr ail(Apthsifdiferenn7(crmrpfr-30200'and.2@100) coastmctiontothefollowing:
10.Static water level below top of casing: - ((b•) Diviaiva of Water Resource.,Information Processing Unit,
if water level is about casfiig;ate"+" - '1617 Mail Service Cetrtcr,Raleigh,NC 2769P I61.7
11,Borehole&eneter':l•5.. • -- '(in.) 21b.Fiir'infection Welts ONLY: in addition
to sending-tile form to the address in
.24a above.also subtuit a.copy of this font within 30 days-of completion of well
12.Well construction method:DPT - construction to the following:
(i.c.auger.rotary.babies direct posh etc., I. '
'Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: •1636 Mail Service'Center+Raleigh,SIC 27699-1636
t3a Yield(gpm) Wilted• test: 21e.For Water Supply&injection Wells:
Also subtitit one copy of'this•forul within 30,daysofcompletionof
33h.Disinfcettaa type: Amount:. well constriction to the county health department of the.cotmtv.nhetc
Constructed.
•
Fonn GW-t N'orlh Carolina Deponnxni of Emrim inriu arad Natural Resources-Divvioa of Water ltmo re - Revised Augtnt2013