GW1-2022-04891_Well Construction - GW1_20220525

WELL CONSTRUCTION RECORD LIPN�tcnwlsc ONLY:
This!aria can be used for single or tr Wlipk n'ells `
1.Well Contractor Information: \ JJJ
tJctV,tTLR'LONIS
Stefan Smith FROM TO pFtiCRIPTIOY
1Ve11 Contrador Name
3576A fG fG
NCWellContmelarCcrliftcntionNiurher I&OUTER CASiNG(rormulll-cascdud134ORLiKER(if a fleableh
FRONT To DTAbiF"TER THICKNESS NIA7ERTAL
SAEDACCO Inc 0 ft, 20 fG 1 2" in. SCH-40 PVC
Conjimy Name 16:iNNER'CASING OR TUBING' ,eoihermal elased4w
FRONT I To DULAIETEe- THICKNESS I NIATEM
2,Well ConNttuction Petm}it 4: R. ft. nL
1"1st allrM,11mble rceilprnuits fix.Counfv,5}rar.,Variatwe.7ryxtie1i.-tr.f
3.Well Use(chccicwrjl use): 17.SCRk.EN
Water SupplyWell, FRONT To DrANrrtnn srorsnt: Tiricrcntjs I NIATF.RIAI.
riAgriculWral ONfunieipaMblic 20 ft, 40 ft. 2" ia6 .010 SCH-40 PVC
®Geothermal(HeatingiCooliog Supply) ®Residential Water Supply(single) it. fG inti
❑bidustriaUConmtercial ©Residential Water Supply(shared) 18:GROUT
FRONT TO NULTERUL ENTPLtCENIENT hrEMOD S AMOUNT
❑reel union 0 f4 16 fG Portland Tremie
Non-Water Supply'Well• R,
Dllhlonitoring pRecpN�r}
Neel[On Well:
QAquiferiteci qp 130oundmilerRcotediatian I9.-sAND1GWkVE'LJ'ACKiit rakable.)
FROM TO NrATN,RTAI• PAT PLIC}:11t:\'f NIETnnit
[]Aquifer Storago and Recovery ❑Salinity Harrier 18 R,_ 40 ft. Sand 2
❑AquifcrTest. ❑Stormwatcr Drmtnagr
rt. rG
MExperimcnial Technology ❑Subsidcricc Contwl
-Xn DRTLLiN G LOG(allach additional sheers if messm l
❑a-olltemud(Closet[Loop) ❑Tracts FRONT TO DF5CRIPTIU\(t»br,r,anlncn,,tri;'nrckH tr.'•xat vrut/r.}"
❑Geothenual(FleaiineeCootim Retum) ❑Other(ex lai►i under 921 Remarlrs) 0 ft. 12 fG Clayey silt
12 ft. 29 fL Silt
4.Date Well(s)Completed: 4-13-2022 .Well t1#MW-4 29 ft. 40 fG Sandy silt
5a.We11 L C1161n: fL fG
Quality Fabricators fG fG
Facilii}'t'OlrncrNnitte Faci it)•iDtl(ifapplicnbkj
170 Parks Crossroads Church Rd., Ramseur , NC, 27316 ft, fG �n-,roll.
3�ry -.5 E ,;.g. , ,•,-
riL-7 iN'T t{�r�r t r4i�'✓C-c;t:ii 113 i
eln-skal.4ddiess,City'.and Zip °21_RENIAPI S'
Randolph 2 foot bentonite seal from 16 to 18 feet.
(sntuly 11artel ldcatifit,111on No.(Plll)
Sb.I.-altitude and Longitude in degmw1minutesInconds or,decimal dgty cs: 22.Certification:
(Ifuoll!nerd,tbrc I ufloug is snf)iclvrd)
35.743693 N 79.579462 W _a* 4/29/2022 -
Signale;Gcd Pt'cll Cantrtcmr___�-- s Date
6.IS(are'the well(.$)r -MPermanent or ❑Tenmpor ary Ify signiub this form,1 frerEby certify that the u•eflts•i was f srvre)corlymicted ire mrvrJrncw
u4Nr 154 NCAC 02C.01(1`t or 1{t NCAC 02C,0'00 Pell Cnn.11M lc,r Sratvhrrds turd tlxri<r
7.L;this a repair to an existing well: ❑ ini .or NNn cr�yof dais nrarri hoc ern prnritlyd tni,4c cnr11 miner,
1f thts'is a relkllr•fill char krt;w well cominicilora ltrform Pion marl a t'plaln the wrare of the
repiirardrr#21 remarkssvrlion or an the.bark of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Nurnber of wells constructed: 1 cous(tuctiou delaiis. You may also attach additional pages if necessary_
For aanlillale ir0'ecrl4?n or oan-m er snpplc wells 0,M i,4rh rlir urrae carrsMarcfttur,yr•4r coo
.s 6niftm,eform. ,SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface 40 (ri,) 24a. Fur All Wells: Submit this form ivilhin 30 daps of completion of well
Forma,lilple ells'linaildepihsVdiffereiu(e•.rarnple-2@e00•m,t1aC1 M- ) construction to(he foilowin ;
10.Static water level below top of casing: ((I,) Division of Water Resources,Information Processing Unit,
ff uwher level is above walla;,tue'•+' 1617 Mail Sawice Center,Raleigh,NC 2 7699-1 617
I1.Borehole diamctm 8.25^ (in,) 24b.Tnr Ftlt dau We[Iv ONLY: In addition to sending(lie four to the address in
24aabove, also submit a copy of this form }silbin 30 days of completion of well
12,Well construction method: HSA construction to dw following-
(LC.aug-cr.rotary,cable.direct push c(c.y
Division of Water Resources,Undergr-ound Ln]cc(lon Control Ptnu'ramn,
FOR WATER S13PPLY'VLLLS ONLY: 1636 Mill Service,Cenler.Raleigh,NC 27699-1636
13;L Yield ftm) 'NIctllod of test: 24r-For Water Supply.k Inject6ts Wc[Is:
Also subtuit one copy of this form within 3o,days of completion of
131r.Disinfection type: Amount:
well constniction to the county ttcalih department or the counh•where
i
constructed.
I
Form G1V-i Noah Carolina Department of Enviiaanxiu and Namrai Resources-Division of Water Rmou Rcviscd August_013