_Well Construction - GW1_20230315 (39)

WELL CONSTRUCTION RECORD Fat rnvcrunl Use ONLY:
nis form can be ttwd far single or Maltip)c twils
1.Well Contractor Information:
Id 3VATERZONIM
Scott Hunt, Jr FROM TO OKIVItlmox
1vdlCorsrdclorNam
4561-A
R. fL
NC%Yell ComractorCcnifrcation Niinh6r t&OUTER CASING Ifor'Qufti-eased ocflsl OR"LMM(if a' Hc2 k)
FRONT i0 DLArr,T@R MH7K'NESS' MATERIAL
SAEDACCO Inc fL IL 1a
Collvmq.Nante 16 INNER CASING OR TUBING willwir A elawd4oa
FRONT V TO DLLStET@R I THICKNESSS I �fATErdL�L
2,Welt Constrluetion pCITUit#: WI0501112 ft. rt, da
list oilrppliralrfr%V11 permits(Le.Cmamt Sta.'s,:Varfaace,JJErdat rlr..)
R, fit. tn.
3,Well Use(chccl:well use): t7:SCREEN
Water Supply Well - - FRONT TO DrAaIETE6t I Sr.OT517S TIaCICNM I MAMMAL
DAgricultu al ft. R, in.
®Geothermal(Hcatitotooling Supply} ❑Residential Water Supply(single) R, fL
©hidustriallConwtereial ❑Residential 1Viter Supply(shared) tut.GROUT ..
FRONT Tt) AtATL7R7AL @MPLICENDENT AIMOD&AMOUNT
❑irrc atian ft. rt
Non-Water Supply'Well:
MlonitorinG C111ccovcry tt. fit.
Iujeeilon Welt; (t, A.
17Ag11ifCf RCCl1aIr;C i7Groundwitcf 11cmcdi;nion M SANDMMAVEL FACK Gr r ilkabtel.
FRONT TO 11,iTF;RCII. Rt'1PI.,LCr:\Ir;NT Ht:Tf1On
❑Aquifer 8,wruse acid Rccov'cty ❑Salinity Harrier R. ft."
❑ArJntfcr Test 17Stormrv'ntcrDrtin,•Ipc
❑Experimental T6chnology ❑Subsidcr►cc Control
IO::DRD,LIti G LOG fonach sdditionat shcetfli'mcessan•1
❑Geolllennal(Closed Loop) ❑Tracer FROST TO nFseRtrrlO\afbr,t+artlnca,wtt'nlck Iv ^N e del
❑ eveliennal(lleadngtCaobug Retum) 001fler(explain mtder#2l Rema") I
rL
ft. ft. -- - --; �•�•
4.Date Well(s)Compleled: 2-17-23 g eRID#B1-B34 (even numberi
ft. R.
Sa.Well Locathln: -• r r
ft. (r. MAR f .. 3
Former Grocery Boy Jr #5 ft. fl
FacilryihtvnorNnnx Faci]itylDN fapplknble) 77)
R.
602 W. Chatham St., Cary, NC,; 27511 fit. fit
Flay si;ii AddressL City.and zip 21.11EMARKS.
Wake DPT injection through bentonite packed 6"
Ccuntly Panel ldealirk Ilion No;(FIN) boring
Sh,i;atitude and I,ingitnde in 41cgr cestminutes/sceonds or decimal dcgrees: 22.Certification:
(Ifs,ell fields one I:unong is%ldfic1 nil) �f
N W ���w 3/1/2023
SlgfuWea of CcitlliCd Nell Ca C[ar Dalc
6.IS(are)we vven(s): ❑Pennatlenl or SJTentporary.. Il3•signing thLr form.i fremb.y eerfifc rhaf fhg irellfs)ntir(twee)coavfnrcted Lit avearrionce
frith 15A NCAC 02C,0100 m•15A JVCAC 02C.,O200 MV11 COMMICt(a(I 5r0rulm15 Mid dxir a
7.CS this a repair to an existing well: i7Yc` or ®No a e�tr op rhls rreaMhrrsfn n prnrirhai to iha to Il mt�u c
rfti'(s is o rep ale,fill rmr A olm well e&wn(ciloa ltrforrnarion and etplahi the narare of the
repair farrlertt»1 remarkr ircama or an the haxl-of this famr. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or welt
8.Numberof wells constructed: 17 consimcdoo details. You m4 also anach additional pages if necessary.
For nnl4ipfe lrfec'rinn'or a(NI-Ivarer si pplr wells OA'LV 1r1rh die s rmecungtrnirinn,wif can
sadrnitone form. S[iBAf[TTAL(NS'C T .TiONS
9.Total well delith below•I:and stirface: 21 24a. (•dr All Welt% Submit this form vviOu 30 days of coniplefion of►cell
ForIM111lpleiceilsl�stall(ieprhrlfdlfirenr(rxarnPlc'-3@200'urr(12@1wJ cominletionto(fie follaving:
10.Static water level below top of casing: 12 ((y,) Division of Water Resource4 Information Processing Unit,
If uuler level Is above cvrs0sd a .+" 1617 Afai1 Service Center,Raleigh,YC 27699-1617
11.Borehole diameter.2.25^ (in.) 24h,Fur Let W. `Ve[Ia.ONLV: in addition to sending ille fomt to the address in.
24aabove,also submit a copy of this fonu within 30 days of completion of well
12.Well constntetioa method:DPT consimction to clue fcillawing:
(i.e.au.-cr..rolafy,cable,diner push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SbPPLY WELLS ONLY, 1636 Afall Service Center,Raleigh,XC 27699-I636
13,x Yicld(gpnl) hl IMI!of test: 74c-For.Water SugV1X&Ji jcctLo.n Welts:
Also submit one copy of this foinl Kithitt 30 days of completion of
13b.Disinfmtion type, Amount: well consintetion to the county health:department of the cou",when
construtcd.
Fana MI-1 Notch CarolLm rA-panntcni of Environnriu and Normal Resources-Division of xlralcr R�soutm Revised August_t013