GW1-2022-05497_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD For ttucral Use ONLY:
This form can be used far single or multiple wclls-
1.Well.Contractor Information:
'IJ:AYATER.ZONES
Scott Hunt, Jr FROM 170 1 DPSCRtIi*r1ON
W01CoMmaorNatno ft. ft.
4561-A fL fL
NC Well CanlmdorCcnifcitionNw&er _M OUTER CASING(for-owhi-cisedsieis"OTLINR
FROM TO HTBRh CK�ESfY's A GLD4
SAEDACCO Inc 0 ft. 26 fL 2.25"
I NA STEEL
ConViuiy Namc 16 1NNEtWCASINGOR--.TUBING;(' ibernale,asedaoa ..
FROM TO D[MIETER, I 1MICKNESS I MAURUL
2.Well Construction Permit#: ft. a: 64
1-ist all oppi rable urIl permits Ox.Camnry.,Fiwr.trrrria,rre,fnya:dat err..)
R. fL in.
J.Well use(chcelc well use): 17.SCRE:EN
WatersupplyWelft Fmc►at I TO MANI.TSR SWTSIM Tltt(KNF-" I MATERIAL
DAgticuitural 011unicipaYP(tblic 26 ft. 30 ft. 1.25" 106 .004 NA STEEL
®Geothermal(Eleatingtooting Supply) ®Residential Water Supply(single) fL I ft. lie.
0Industrial/Commercial C311esidential Water Supply(shared) 18:GROUT :.
FROM TO MATMUL EMPLACL,MT3411MOD&MIOUNT
❑Irrigation ft. ft.
Non-Water Supply Well:
R. ft,
Qmonitoring QRccos-c(y
Injection Weil: fl. ra
ClAquiferRcchirge MitoutidaaicrReincdiation ' SANDIGRAVELPACK'(if tdleabri
PROM To MATRRIAI. Estrt tic ern yr vttzu0n
QAgtrifcr Storage aihd JtcceF'c(y QSalinity I3arricr R. R,
❑Aquifer Tcst QStormw;ttcr DMMgc
rt. rL
Mxperimcntal Technology QSubsidcncc Cerdtol
2oJDRILLING'WG'(attach addiiieaal stxeti if-accessan
QGeodiemkal(Closed Loop) 13Trdeer FROM TO DESCRIMON(mbr.bardnevi soWt%xk typt,gWOrue de.)
QGeattennal(Headt'Coo[in Retum) E3011ter(clam under#21 Remarks) ft. f4 See Geologist's log
rL ft.
4.Date NVA(s)Completed: 4/22/22 WdlIDgsl-Blz
rL ft.
54;Well Lttcatinn: ft. (L
NCDOT Parcel 90 ft. rL " ,1
Facilityi0m,ncrNamc FacilkIDN(Tappliable) ft ft. J
4509 US-311 , Randleman, NC, 27350 R, rL
Pltyskal Addicss.City.and Zip -2t.RENIARKS
Randolph Direct push injection through drill rods
Count), Parcel Wcnlifealion No,(PIN)
5b.I atitude'and"rigitude in degmes/minutes1seconds or decimal degrecs. 22.Certiri"thine
(Ituell field,ome kablong is srrlttcicug
N W 5/21/2022
SiPg31i 'arCeatlicd Well Can tar' Date
6.Is(are)the wcll(s): t7Permanent or Temporary hh,s{gnbrb this form,1 hereby certify rhea Mr imll(s)liar(wrn)cy,cvtnreted in aecordan
n'ith IM NOW 02C.0100 or 15A NCAC 02C.0200 Well Coirstiricrion Starxiards and sMi a
7.Ls thin a reliaie to an ceistfng w'dl: E7Ycs or ®Nn copy of thlr reeorrf has breri pmvirkd ro tier wxll mruer.
1f ri.ls&a repair,fill tRrt krniuvi uc!!earunuclron hrformorlcur,md ctpiahe rho eiarure of the
repair umrlerA31 remnarla srctiin or on Me back-of thix form. 23.Site diagram or additional well detait3:
You may use die back of tills page to provide additional well site details or well
S.Numberof ivells conctntcted: 12 constmetion deiuils. You tray also attach-additianal page's if uecessaky.
For m,ilrlple lydeetinn or rimi-isarer supply ivells ONLY u'hh the same consa'Rctlat,you can
sar(arrif one form. CUB611ML INSTUCTIONS
9.Total cell depth below land surface.: 30 (ft.) 24a. Far All Wells: Submit this farm within 30 days of completion of well
Formutdple,wellr list a11depAsltdlferesit(eramPie-3@200'ari12 IM) constnictionto the foltavirig;
10.Static water level below top of casinW. (ft.) Division of Water Resources,Iufornmtion 1 rmccssing Unit,
If n'ardr level&above casGt„use"+" 1617Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.2.25" (in) tab.Far JilleclJon Welb ONLY: In addition to sending the fomt to like address in
24d above.also submit a copy of this form within 30 days of completion of hell
12.Well construction method:DPT construction tD the following:
(Lc.augm rMq,cabk,direct push e(c y
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i636 MaH Service Center,Rai cigb,NC 27699.1636
13a.Yield(gpm) Method of test: 24c.For Water Sbaply&Injection Wells:
Also submit one copy of this form within 30 daysofcompletioaof
13h.Disinfection type". Amount: well construction to the co(mly health dcpartment of the county where
cortsmictcd.
Fans G%V-1 Noah Carallna Elcpaeme:vt of Erwirorunent and Natural Resources—Dtvi0oo of Waicr ltMures Rcs'lsed Ai0ist 4)13