GW1-2022-05247_Well Construction - GW1_20220531

WELL C'ONSIRUMION RECORD FgrtttcntalIL! ;.QNLY:.
This form caii be used fr T-singic ar nmltijilc wells
1.1rYell-Ci ntr tetor Infortuation:
14.AVA tER ZON F'S
Stefan Smith FROM TO hTiGR1F110Y
Well64radrrName
3576A ft. f4
NC.WellCoritmclorCcnifteationNiudicr IK OUTER CASING(for mutil-civNI e"OTOR LINER Ofa`ileybM)
FROM TO DMIETER, TUICI MSS li1ATLRUL
SAEDACCO Inc 0 it,1 40 (L 6 1in. 1 40 PVC
Corignwjj.Ntunw- 16:IN`:ER CASING OR 771BING teidbrrrna)cluFed4L4i
FROM TO DU:i1ETER. 'f1rlc"Fss 11L1TERL1f
2,Wcth•±Cnnst�vctiiin 1'crnrlt t:; R, rt.. `nt.
list rrlduFyilirahlr v.`ett jrcirtrjtx(i:c.Counht�Stutc,'.)rnr}sasses,Irft�bw}�Jr,.J
3.Well.Use 0fieckWell use): 17: CREEN
WslterSnfifikv Well: FROM To nrAMETM SLOT517F TnICKNF$ �S S' rATRRTAI..
❑Agrku,Ittial Mmunicip.vmblic 40, R: 60 ft.. 6 in, oao 40' Stainless
®Geothermal(Heatingto0iing Supply) OResidential Water Supply(siDgle) fi' fL to
13ludustriallConmicicial 17ResideutialWater'Suppb*(sbared) 18. ROU1FROM •TO bU1EnLAI gl[PL-,C£\]LNT\fETI)ODS,th14Wr
191hi anion 0 ft. 35 (t. Portland/be' e3ite
Non-Water Supply Well: ft. It.
dMonitoring �Rcv m'cry'
Inj,eclioIT veII: ft. rc
QA,tliddr1tcchirge QGinITTid)tltcrltcairediatian 10 SAND.'GwA..rGEL ACKfita plicalr41
'FROM To atATPHIAL R P1A(X%tF_VT!nk"rn(ln
QA[itnfcrStoia�i aTilltecove,ly QSalinih Barrier 38 h.. 65 ft" sand 3
QAgiiifcrTcst Q5tormtixitcrDiainn�,o ft, ft.
dV.VpAwcnIal7hh1a(ito Q54tb5idcnc Cdrwml 20;DRILLING LOG(Ml icd atldiii6nal sheets if necessarvl
❑Gcothennal(ClosestLoop) ❑TrdcLr FROM' I To DFSCR1Fn0N'(mbr.ti rdtivx4.,4-i11mwk1 a cegirt.)
❑Ckotliennal(FleatitteejCooliug Return) ❑Outer(aeplain under A21 Remail s) 0 ft'. 17 ft, Sand
7 ft., 23 (L clay
4.Dtite NVelI(s)Coitiple1ed: 43 Feb 20236111D11EW54 r' p
23 'ft, 38 it, Silty Sand
U Well t.tteatiou: 38 ft. 40 ft.. Clay
Chemour 40 ft. 66 fL Sand
Ftcililpidivnl:r3}anra FacilityIMD ekzPpiic:tblc) 66 N. 70 ft. Clay ii
+
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, fb f4 s
White Oak, NC, 28399 pji.sikIIAAdt£SS.Cdt}•.:Ind Zip 21.iCEM1IA[t1iS'
Cumvberland Well installed with 51 stainless steel sump.
C�qu1y }*drcG It1.rrlirieatiPn No,,(PIN)
I.l.;Ttitiidt and il.pngitudc in cg veslminutts1kconds or'dccimal dcgrecst 22.Certification:•
(Irxiyll1104axw.hli,'lot is ttfCelznO I n
34.839540 N 78.825955 �1' Sy'�! 2/13/2022
Sigti�r afCc.. edZ4'c1lCantnSwr' Date
6.1s(are),the wcll(s): MPerniunent or oTeniporats'
By�;gning thin feprnr,-T$xrrLy�arflfy i'hrr1he nY!!{y/ts-ur,{i.'rrerJ ectrzarnrerrd im:Fce.roXrlmirr
ivith"15,1:CAC 02G-.0102 or.1.TA AVAC Ok,42017 M 11 ronsliTiction Scan arils road flair h
7.Lv this d n flair to an,eiistini v'clli El Ves .or ®NO lams&x raj lirrmide-d rh Me rtrll owner,
d f of lc ds o rtl rlr,fr1T tnrr ifiiXnW Tr edd cYNutnrcrlorr hlriamrrsrlcur aril ra{rlcriil the nararc of r11e
rrvuir rmird� 3T�'d son rkr:iYainnm ar cvi rlir ha k q,(fVx fnruL 23.Site diAgratn'or additional well details:
You may use.tIk back of this pa&.to"proxdde additional well site,details,tir tell
S.Number or*elis constructed: 1 consftuction deta&.; TPou Issas alsei sUacliadditiirtlaEpales"if ileccssar}.
For imiizWe dr{I�>ri�untN n i-i+�Trar�rppJp l+ '1t1 Lih'LY wirh rlie some ruiistrrrcrdar,yeur,cxTn
.rmNi t rmr fi nm SUB tiITTA L iNST T .TiOIVS'.
9.Tafa1 well depth below land suriuc>M 65 Ut. For all Welts; 'S)ibutit this four within.16 days"af complcti6d of$veil
For rrraingeµeffi''Sirirfl,�6-fj4ervfl constructiontoilicfollowina:'
10.Static water lei'el Ulm top of casing: f[lt.) tlis•isidn of Water 116ourm,informatiun Ptueessing Unit,
df metre(lettellx abol!e eti;slr;_;use"+" 1617 Alai[Service Center,Ralcipty SIC 2 7699-1617
114 borehole diameter.:L0 (in) tab.Fnr iaijWJ Wetly ONLY: In addition to sending the form to the address.in
24aabode:also submit a copy of this forin within 30 dal'Sr or coupletion.of htA
12.Well'coustructiou inethod: sonic eanstmclioti t0 tIte.folloWine:
(Le..anger.rafaip.cable direct push ctc.)
Division of Watex Resources,Underground injection Control Proggrain,
FOR NVATERSUTPI Y WELL50NLY: 4636 Mail Service-Center,Raleigh,NC"275994636'
i3 k Yidti(gfinr) llctitod of test '-tc..For hunter Supply-K injection Wells:
Also submit one Cdpy of this fofin within 30 daysofcompletion.of
13b.nlsinfet`tion,t+;pisx;. Aainunt: vvcli-constriction•to the county liealth deprtrtment oe The:coitntv.xvtaere.
cartstnictcd.
Farnr GlF-( Nonh Carolina Mporoncitt.of Envirotuncm am Natural Resources—Divulon 0MIaler Rrwtrcm Rcviscd August2(Y13