GW1-2022-05472_Well Construction - GW1_20220601

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WELL CONS'iRUCTION RECORD For[tic mal Use ONLY:
Ms form can be used For single or rnnitipk veils
1.Wdl Contractor Lrfonnation:
'14.IYhTER ZONES
Scott Hunt, Jr FROM TO DESCRIPTION
Welt CordradorMime
4561-A
NC Well Contractor CcnlrLealionNutuber AS.OUTER CASING Mr M-014isid WeNO ORLiNERfita []cables
FROM To I DLLAIETER TItYCiu�E55 hIATEfltAL
SAEDACCO Inc 0 ft. 10 ft 2.25" in. NA STEEL
Cametn}Name 16JNNER CASMG ORVUBING7lizetaberntatclosed-lon ;
FROM TO DMIETER TnlMNESS. A1ATETdkL
2.Wcll Construction PctTuit#: R. ft,
1ist411 appilicable wd1permits(cr.Comas.Stair,Variam e.Infa:664 or,.)
ft. ft, in
3.We11.Use(chccl.well use);
Water Suppkv Wcll: FROM TO DIAMr.T6R srorsizt: I WICKNESS I hIATMIAI,
OAgricultutul ❑Nful icipa.Mblic 10 R, 14 R. 1.25" in. 004 NA STEEL
Meothertml(HeatiggfCooliog Suppi,Y) ®Residential Water Supply(single) R. fL ire.
ObidustriaUConmtercial ©Residential Water Supply(shared) ta:GROUT
FROM TO MATERIAL EATPLACENMT AIEMOD&AMOUNT
okfigation ft. fL
Non-Walter Supply Well: fL phllonitoring pRRotrry fL
tnJe.ctton well: n
QAqui(cMdarge EGrouridnalcrReincdialion 19:SnNDIGttAVELPACK(if- t slieW)te)-
I]Aigtitcr Storage and Rccovety ❑Salinity 13arricr FtatoM Tax atATlsRwt, ESrat sc t�u:Nr Mt7ltnn
QAquifcr Tcst 135lommatcr Dratim'"c
rt. ti.
DEXPCrimcutal Tcchnotogy l7SuWdcncc Control
20 DRILLIl1GLOG(attach additional sheeti U o"esmni
❑Gmtherniai(Closed Loop) ❑Tracer .FROM TO DESCRIMONrsnbnhardmi s"tl'nkktr w,,e ck:t
❑Geodtennal(IieatinglCooliu Return) ❑Otherreeplaitt under 921Rewa&) It. ft, see Geologist's log
ft. IL
4;Date Well(s)Completed: 5/3/22 Well E[)#AI-A16 fL (4 dQ, a.
Lf-
Sml Well Location: ft. tL
LC Hudspeth (L A.
Facilit)Ahvi crNama Faclhy IDk GTapplicablc)
R. rL 1f11"iiG6r -i ePFo-1=-H rwi
5891 NC-90 Lenoir, NC, 28645 fL ft.
Physical Add.ress City.andEip 4,2L REMARKS
Caldwell Direct push injections with tooling.
GnnW}' Paste]rah ulitis1licn No,(PIN)
Sb.Latitude'and Longitude in degrees/minutes/seconds or decimal dcgrecs: 27-
Certitirath:a:
(Irs,cll l'kld,Wrc 101ongis sn(ticicrd)
�V �C.d��u� 5/21/2022
Sigmturc efccit(ftcd Well Con etas Date
6.IS(tut,)the R'ell(s): ❑Petntanenl or SlTemporary 11}•signhtg ihir form.1 herebY certify Mor rlie ivell(s�l t+vr(ward cominrcierl ire accordance
with 11%NCAC 02C.01(k)or ISet NCAC 02C,020P Well Constmoriar Srarslards and rlxrra
7.Is this a repair to an ed.Wng well: l7Y4w or M Nn CofrpaidlfT rerarrl hRs b,?nl pnrrirkd m t1r url!roarer.
If this Is a rep-alr,fall eert bataurr well eotumrctloa brformaxion artd nplobt Me iwrare of the
repair rifler 921 remarLs rcriara or m die back of dfis form. 23.Site diagram or additional well details-
You may use the back of this page to provide additional well site details or well
8.Number of wells cougructed: 16 construction details. You may also allaelt additional pages if necessary.
For itudrlpie i*erlon or not-it'arer supply aclfs OA'4Y a'hh rbe some eonstri4don,you can
srr(mrii one form SURNIITTAL INSTUCTIONS
9.Total well depth below land surface 14 (f►,) 24a. For All Welbi Submit Iltis form within 30 days of cornplction of well
Fortnr11r1ple wells list alideprhslfdifferewee aoiple-J%e:00'and2@f(t(t) construction to thefgttanin�;
10.Statie water level below top of casing: (()(,) Division of water Resources,Inftlrtnation Processing Unit,
1/muter level 1s above casing;am"+" 1617 Alail Service Center,RAleirlt,:NC 2 76 99-1 6 17
Il,Borehole distmctcr:2•zs" (in) 24b.Fnr Ig[ce l wetly ONLY. In addition to sending the form to the address in
24a above.also subtuit a copy of this form within 30 days of completion of uell
12,Well coosiructiou method: DPT L'ollstrucliau to the follotvhlg:
(Le.agcr.ratar}•,cable direct puslt-erc.)
Division of Water Resources,Underground Injection Control Progran►,
FOR WATER SUPPLY WELLS ONLY: i636 Mail Service Center,Raleigh,NC 2709.1636
13a,lucid(gprn) Mcthod of test: 24c.For water Supply&rnicction Wctls:
Also subritit one copy of this form within 30 days of completion of
13h.Disinfection typet Amnunt• Wcll construction to the county health department of the county where
cartstntctcd. '
Farm GW-t Nonh Carallaa Depanruent of 8mdronmetu and Nan"Resources-Division of 1Z'atcr Re autos Revised At{g M 201:t