GW1-2023-00366_Well Construction - GW1_20230103

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WELL.CONSTRUCTION RECORD" Parlrrzcnwttrs*ONLY: 4'
This form cm bcawd far siegic"multiple wells-
I.Wet[Contractor Information:
'44.IVAT12R ZONES
Zach Thompson FROM TO DRSCREPrION
11'cJEConingvrNann: R.
4478A 2 rL I
NCNcIICammcrarCcnifrc�tionNulrtirr I i9.OUTER CASiNG Nor eru111-eised-cAsI0
RLIlYERlE1u"lkatik
FROST TO DL�L5IFTRR THICKNESS \1AHERIAL
SAI3DACC0 Inc 0 rL 40 rL 2° ia. SCH-40 . PVC
Conp�;vr}Nauq 16.INNER CASING OR.TUBING ikerniat chmd4oa
FRO,Vr To - DIAMETER'- THICKNESS MATERIAL
2.Well Constmetlon Pi"T"It#: rt. rt; 64
l rstaft a}.pilirable rsrltpehirris fire.County,Sena.;Varlamce•bye:dar;�Ir,.J'
ft. ft, in
3,Weil Use(eheclewdl tisc); t7 SCtt1EN
Watcr5uppl�'1'Pcllc - - --- FROM TO DLt1rET6R SLOT5I7Y THIC1 M_ brATrrtdrAr.
40 ft. 70 ft, 2° iiu .010 SCH-40 PVC
®AgrBciiltgtui_ CI14tuniaipaUPnblic '
Mkothelmal(HcatinglCooi ug Supply) ®Residential Watei Supply(single) ft. ff. in
®isTdustriaUCommeecial 011esiden[ial Water Supply(slatted) ie:GR©[rr
FRONT— TO STATERIAL EiNU CEhIENTME HOD&AAI0UNT
❑Teri"'rNon . ' - it. rt. '
Non-water Supply Well:,
ft. tt,
!�)Vlonitoring MRccorcvy . . ,
injection Well: R. It.'
QAntiifer Rcchargt Q0rouMV:tter Rl u ediation °t9.'SANDIGRAVEL PACKTif Ileabte)`:.
. 'PROM ' To D1A!MRL%I. RUPIA(:I:Ni:,NTMt-rH0n
1]AQnifCr-Sto?afy6and}LSCOfSt}° QSalinityl30;ficr. 38 R. 70 ft. Filtered Sand #2
l7Aslaefcrlc� A5tomm�tcclhaina�c �
❑ExperimcntalT�chnoiogy. USubsid-rnccCoidml rL I
- `10 DRiLLIl�G'I.OG raltaeh addE(iouatstieets it ncccswry
l]GtsJdtenlwl(ClaserhLoop) OTraCer 4110111 TO• DESCRIPi10. mbr.t;atdoea wWmckh nF6aaicl
OGeodieal(IleatinglCooliue Reitmt} [3Other( •lain udder#21 Remad sl o ft. 7 o rL PNIR/Sand
tur
ri
4.10ateNVe1l(s)C1onlpleledi 11-15-22 WMIDOW-5; tt- r
S&WdI La►catton:, fL" fL
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Vickers Village rt rLJAN
Facaityr'O►s•acrNane Fuciffty IDk df4piiabie}
271 Jack Bennett_Rd., Chapel Hill, NC,- 27517 R. rQ �.. i3t1LWA
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PhysiedAddrcsi City,andZip 21:REi[1AR[tS
Chatham I' Bentonite Seal from 3611-38'
Convty Marcel tder119 V1.11un No.(PEN)
Sb.I-;Atihtde and I rigtinde in dcbniseclmimtteslseeonds qr ilcsitiral dcgl scs: 22.Ccrfil'eratiga:
(ifssrll field;one 1,lffloug is RuflTekrd}
35.81733- N -79.07507, WN! 12/4/2022
lgnnpc' Cgh'F l wen Conriactarr Daic
6,Is(mm,)We.well(s)r oPermanent or," 81')iempor&7 BY rrg,rhrg MIS form,1 hereby certify didt the uellir)tsar(hero)4WM1n1ere4 br;ot'eorthincle
iyith IM NCAC 02C,01A9 or 15A NOW 01C.029D M11 Conilmeriorr Standards mid tbrrr a
?.Lc thin a ri paiirto sat existipghell: t7Yea or 20NO; . copy of rhxs meonihrrsbrni proykkd ratl�r aril tnr'arer.
1/ihls.is,it repent.fll airAvinvr Ivell eaatsrrarrrloa brforeaarlon amtl e%plaht the tkrrrare of rlie
repair andere*21 remarXsercdan or w the hwk of thisfarM 23.Site diagram or additional ivdidetails:
You may use ilieback of this page to provide additional well site-details or[sell
8.Numbetrof wells constructed: 1 constmetioil deiaifs. You may also attach additional pages if tiecessary.
For imkVl AtWilm orouvr-unrermppry wells VLV akh the.smileconatrireirorr,you can
sabririe oar form. SUBMITTAL iNST[TC pi@NS
9.Total well delith 6ehow land sItfgeet 70 $?.) 2aa Htic lIll Welh. Suhridt this fdIm within 30 days of completion of[veil
Fororttlilphrivelrtlisralidep?rhsIfd errnllraaalptc-3@200°rxrul2 ddlll}' consimcdonto the follovOug;
10.Static water level below tap of easing: A) Division of Water R6ourccs,Information Processing Unit,
If maser level h uboya cvi N&use'Y' 1617 Mail Service Center,Rate rnh,NC 27699-1t 17
11.Borehole diameter,6° (in,) tab.jot rnlceilon wepa.ONLY: in addition to:sending the faint to the address.in
24a above.also submit a•copy of this.fame within 30 days'ef completion of well
12.WdtaottstenctioD method: Sonic I .eoltsimction to the following..
ti.c.migan.nmoy,calif direct pask etc:} li
' Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Sert'ice iCgnter,Raleigh,NC 27M.1636
13,T,Yield(gj►m) Method of test: 24c;For%VatcrSannly&fpjectian+Nyells:
Also sub"t one copy of this fonu within 30 daysof completion of
13h.Disinfeetian,type: _ _ Amount: swell construction to the county ilth department of the county where
coostntoted,
Fenn GlV-L Norih Camllna l}.Wantenr of Pwiro m:N attd Nanual Resources—DEvislon of Water Rewtroes Revised Atigtutll►E3
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