GW1-2023-00365_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD +`
7M form caa bo used for single or nad-fipk twits Far[tRcrtwl Use ONLY: I
1.%Von Contractor Information:
'14:,tVATLrIMONFS`
Zach Thompson' VRp41 To,. OMCRIPT109
1%el[ColliindorNanrc R.
4478A f6 ft.
WC Well CorrMcwrCBnifotlooNwthir 95 OUTER CASING(forsanitl4d9cdricOsl OR=LINER([f'a"'flea6k:.
FROM TO DrASIE.TElt TTitCr-9 MATEtitAL
SAEDACCO Inc 0 fL 35 fL 2". ja, SCH-40 PVC
Conslt urp Nam 16.INNER CASING OR TU®ING eatherrral clascil4ou .
FROM 170 1 DMIETER I THICKNESS I MATERIAL
2.Wc1I Construction Pewit ft. ft.
Lirrull appilir.AAble'mip-rArraits(i.e.Caan%Slaw,Varlarrce.TiyaWa;tic:) i
R:
3.Well Use(che do wen.use); I _ .s EN
WatcrSupplywcil: FRppt I TO OtASrRTFR $LOT 517E 1"IT ESS +rArlaRrAL
Orlgli ultuial• ClIvfuntclpallPubA e. 35 R. 1 50 Qi .2 in," .010 SC11-40 PVC
®Gcothenml(Heatingtooling Supply} Mesidemial Water Supply(siogle) 11 fL It. in,
O lndustri&Conimetcial Glltesidentiat Water Supply.(shat ed) 28 GROUT. "
.FROM! TO. NIATERUL EMPLtCE&MNTMETHOD AMOUNT-
DM91101313
Non-Water Supply Well:
MMonitoring l7itcco%ety, ft, tt
Injection Wen: rG ft.
tlAIilllfef1RCeiltltb8 [3GionrolaalerRelnsdlalon 19SANDIGRAV@L PACK'(if elicaeh)"
Trl MATPIUA KNIP1�rMUNT WIFTROn
t 1Agnifcr Storage arid ttedovet} 175�IiDity Hairier 33 R. 's'o ft. Filtered Sand #2
17a4tlnifcr.Tcst C7StbFM' iNatcr dtaiet,'ipc '
DS aycaillcnfal TcO0.0togy Mub5idcricc6*ol
1aaDRILLING'I UG'(orlacd additional stice(s lfnceesmrV)
OGeolhemtal(Closed Loop) DTracer FnoM To 0MCRIFTION mter.IraMneti+rutrnxkfr , tr*c.ck•.l
OGM[betlnnl(fieatinglCaolina Retum) M er(explain under 921 Relm&) 1 0 ft. 47 ft, PWR/Saad =
47 fL 50 (L Granite
4.Date Well(s)Compkted:• 11-18-22 WCUID#MW..-7
R. ft.
SR.Well 141calion; ft. f4 - ,f '2�, •�-F�
Vickers Village , ft: ft. - ,
Fact piftnerNaltre Fact fly IDN(ifappltcabW 4 c 2 �
ft. ff, VJ
�
271 Jack Sennett Rd., Chapel Hill, NC,. 27517
IT. ft* F..,. ?hen�;i:G�ixfiSF.rl Ufa:
trltysical.tiddiess City!girdzip a2LREMARKS u„v
Chatham 13entonite Seal from 311'-33'
CUntsl� Parcel W211ifoltunN0,(PIN) f•
Sb.1,4ttilvdc and L,ongitadc in deb+scclmPnutcslsceonds nrdccim tl dcgrocs; 2L Cerditpt[nD:
(If»ell Crefd;pare 1,'gAuarg[S Srrplcknl) - .
35.819131 h7 -79:075972 W 12/4/2022
4?lgnxurrofCerti[kdV4e Ce We
6.Is(are),the rsell(s): DPermanent or. mTemporary.
tlf aigabts Ab f Ism.I hereby ernijy Mar the rre11(s)Mar(nrrnl wrairuered hrarwrdmce
n'&h 15A MW 02C.0100 or,ISA NCAC 02i7,02M Well Cnrrstr I Moir Stamitirds wid rlxrr e
7.Is thLY a repair to in cxistiag%vellq l7Ycr or ®Nn. copp oj`f/ufs rerarrd has brsa pmrlrlyd(�lily lull inyrrrr.
ljthls is a repair,fill ourla7artw we&orawttaloa brjamwiion awl cap(abl I&iwmre of rlrr
repair nrirlcrai21 rrrnarks arctiav arar nc�balk of this j"rnr. 23.Site dlWarn or additional%ti ell;detai[s:'
You miky use the back of this page to prod additional well site details or%sell
8.Numberef%tells constrlcr.W: 1 cousuvction deiaiis. You mak aL ,attach additional pa8es if twee-ssary.
For ilriple b�ecrlon ar oM1-ubnr supply rvrRs DNLY trldr dJJ.aamQ rOrrstrnCtlMt,unit roes �
zrAaAri(,oAc form. SUI WItAL MSTUCTIONS
9.Total well depth bertr0land surf Iam 5o 24a. Fur All Well w:' Suhinit this fpmr within 30 days of compleli6u of%hell
Pormalfipfirw1lslraraltdrpthr(fd iirrnr(exaetptc-3@200'aru12@1G0)' eonsthwiontothefoltoVing
10.Stacie water level ticlriw top of easiak (ft.) Division of Water Rc:iources,.Infnrmation Pmieming Unit,
ljnvtur legit h above crta(ag rut"+" 1617 Afail sen'ice C tutor Ralcigb,NC 27699-1617
I
11.Borehole diatncler;6" (iu.) 24b-Far FULU I[Wella.ONLY; In addition to.sending the.form to the address in
24d above,also submit a copy 6f this faunwithin 30'dgys of codipletion of welt
12.Weitcoustruction method: Sonic construction to the following;
(Le.anger.today,cablesect dir p+r51L dC:)
Division of Water Resaurces,Underground Injection Control Prognim,
FOR WATER SUPPLY WELLS ONLY.' 1636 hfnH Service fCeuter,Raleigh,NC 2'7699-1636
13a.Yield(lglm) Nctiwd of test: 24c.For Water Sannly&-tnlectlonl Wells:
Also submit one copy of this f6hit witbkL 30 days of C01130letion of
1311.Disinfection type:. Amount. %yell conamction to the county fie I Ith department of the sourly where
constnuctcd. f
FarmG%V-1 NotchCamllmDcpwtna-nrofPmirDIlnrm and NarWalItCStIUfCC9—Dt1'Ya[OnOrW�l�rReso tes RevisedAtugost_N)13.
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