GW1--03766_Well Construction - GW1_20230602

WELL.CONSTRUCTION RECORD Air Tetanal Use ONLY:
- 'This form can be used fm single ar multiple wells•
1.'4V elt.Contrattor Information: . •
'14:.WATERZONES.
Stefan Smith FROM Tp •DESCRIPTION
1t'c11 Cpraraclot h;rtnC
' ft. ft, f
3576A fL fl
NCWcIJCommciorCcrtiticationNun/vet iSAUTER CASING(for:halal-raved-nelTsl"'ORLiNERfif'sji fklible-- ..
FROM I TO ' DIAMETER THICKNESS MATERIAL
SAEDACCO Inc f4 ft. 1n.
CoingruryNninc .I6 INNER CASING OR=T IBINC/t:ihiiie'mal rru'sr:i1-hoiijrt.;•''- . ..
FROM To . ' DL•ANITTER THICKNESS MATERIAL
• 2.Well Construction Permit#: R. ft, 'in,
I st ill alyiliralde trellpeanits(ix.County.State,Variance,Ifje:101 rJr,.1
- •ft. ft in
3: lr'c11 Use(elteck well I1se): t7:SCREEN
%'iter Supply Well FROM TO DIAMETER s[ArSi73; TIIICKNI S J MATRRIAI,
DJAgricultulal CoMunicip4aliPRblic• R. tr. in
Geothermal(HeatingiCooliug•Supply') ❑Residential Water Supply(single) iL I fL• in, •
®
T e
©industrial/Conmtercial ©ResidentialW4rater.SuppIs(slkltrd) ''R-GROUT .. r -._ ACD- . .. I ..- .. - . .....
Fitoal To MATERIALMATERIALarplucrr�r MerrtaD t.UrlouNr
❑Irrigation tt. ft.
Non-Water Supply Well:
ft. ft:
65hlpnitaring ORci orcty • - — -
Injection Welt: ft. rtr • .
pAquiferRcdtiarge (sl(i[outidRatcr R.citlediation. .19:SANDiGR,tVEtrPACK'IifhltpIkit hu). - - - T.-.- -.' .:-- - ' - _ . .
-.PROM TO • I MATERIAL - -I tPIAC.L%U NT MtTIIOD.
ElAgnifcr.StorJgc and Rccar ay_ l7Salinity l3ame' R.: ft,
❑Aquifer'rest ❑Stornin;tter Drainage ft, ft,
OE-perintental Tcchnok' y IDSuhsidcncc Colytol
20 DRILLING'LOG7allach'addltionalshirts•ititccessaTO
❑Geotltemm((Chisel Loup) OTracer FROM TO DFSCRIPTiON(telar,hannrca,xinlnir4 hex,V.PRii +a.M.l
❑Geothennal(Ileatine Cooling Return) • ❑Other(explain under i 21-Retnat1s) 0 .ft.., 14 IL silt•with sand lens
14 IL 30 fL sand ,—" �.--s q c)
4.Date Well(s).Carnpletcd: 5/4/2023 Wen iIWRDC-9 'ft. • It., ' ":, .—° 4 ,s ""'a'-'.
5a.Wall Location: .ft. • ft. t r. i) 'ZO2.3
,t,t It .1
} ! app. ft,
Facilit;Cen.rNunvc Facility IDSC li nblcy15‘ i�a:
Pearce s GroceryR- ,
fl. lfia�i�`�":F��� �r�
4695 Pearces Rd., Zebulon, NC, 27597 ft. . ft. - .
P It)sieaI-Addnxs_Citq.andZip '21:REhLtlltticS'
Franklin DPT grab sample using SP22 sampler at 3 intervals
County Parcel lddsrnitioatlouNo.(PIN) 1 .
511.I:Hanle and Longhand.in dcgrces/mutates/seconds at decimal dcgi rock 22.Certification:-
(if nett fx.td,ow IaI h fig is'ndlieient)
•
35.916147 • it,- 78.307203 W _ _0 " 5/9/2023
Sigml afCcWifiedWellCantactar' Data
6.Is(are)thelveli(S): ElPertnaneltt or %ITemporary itys grling this biro,.lherrbr certify that the well(s1 i (nun!)coagrirctcd irkac orsltrrite
filth 15.1 ifCCIC 02C.0100 or 1.SA NCrIC 02 C;o20o Welt ll Coustmeritul Standards and guild
7.Is this a rejr4ir to an eiistin„well: l7Ytu. or RIM) rtrylpof this rre(ITS bets 147n pmrided ro hoe art/mrn,•r,
Ifrhr's:R.o relxrlr.fill rot.iBniw.z Well0ounirctioa brftroiork'n mxl r vplal;l rhe tutrtue(Ole
repair raider N21 rcrnar.Ls.section arch The.bark of this form 23.Site diagram or additional well details]
• You,may use the back of this page to proside additional.well site detailsor Well
8.Number of Wells constructed: 1 cotrsnuction details, You May also-attach additional pages if tacessary. •
For m aitlpk 1rl(ecrion or riot-Herter supper netts ONLY mirk rhrsmnc smrstrurtiwr,you<'tw
submit one form. SUBMMTTAL iNSTUCTIONS
• 9.Total well depth belt)*laud surface: 29 qty. 24a. Far All Wells: Submit this fanu within 30 days of completion of well
For nriAlplcirrlls list all depths ifdi i.rrnr(exompre-,?@2ftrreal2irtort? construction to Ike Cottoning:
10.Static water level below top of casing (fl) Divistun of Water Resources,Information Processing Unit,
If water level iv above casing,isle"i-" 1617 Mail.Serrieg Center,Ralei)h,NC 2 7 699-16 17
II.Borehole diameters 2.25" (in,) 246.For ItiJcct!(m Welly ONLY: in-addition to.sending the form to the address in
24aabove,also submit a-copy of this form within:30 days of completion of:tell.
12.Welt construction method:DPT cotrstnictiou to the follott-ine:- '.
(i.e.auger,rotant cable,direct pink etc.)
Division of Water Resources,Underground rttjc►liou Control,Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,i.1C 27699/636
13a Yield(Om) Method of test 24e.For Water Suttjlly&lniretinti Wells:.
Also submit one'copy of this;furlil Within 30.days ofcompletiottof
13b.Disinfection bile Amount: _wctl contraction to the county health department-of the county where
constructed,
FomiGW-I NonitCarolinaDepanmeniofEnvironmentandNaturalResources-Divi;ionofWaterReauLs Revised Augult 2013