GW1--04168_Well Construction - GW1_20230623

WELL CONSTRUCTION RECORD
For[trrarnal Use ONLY:
This font:can Ixt used for single or Inultipk n•ens
1.Well•Coutrrtcfor Information:
14..AAYERZONIS G :I• • • •
Stefan Smith FII031 TU DFS(:RaFtifIN
Well Coiitactot Name ft. G. I '
• 3576-A {t. fL I
NC Well Contractor Ccnification Nnn•1:cr yS:OUTER CASING(fowmulil=F:isa-nelkl OR LINER-614D iticabk)•
FROM To DIAMETER TRIMNESS 'MATERIAL
SAEDACCO Inc ft. ft. is •
Canrp:my Nanle -I6.-INNER CASiNG'ORTUBJNGyldeaibcrival clu ed-luiijo)?: =-
FROM TO DIAMETER TIRCKNESS MATERIAL
fa
2.Well Construction Pen ; WI0600241 R. r
Permit "n: '
Litt idt cpplir-rrbk xrl!penile(ie.Coanrrc.Sro4r,knrinrxe,fleaka'l eir.l R. ft. • in.
3.We11 Use(check well Use): •.17:SCRE.EN . . . •
Water Supply Well: 4 FRO51 TO DIAMETER SLOT Sins: TIIICkNI S 1 )ATrnt.u.
I:IAgricultural tJMtinicipabPublic R. ft. in,
OGeotltcmtal(Heating7Coolimg Supply) ®Residential Pater Supply(single) R. I fL tn,
r t8i GROUT': • _.....
Dlndnstrial(Conmtercial DResidential RDIar Sllppl}'(shred) FROM TO. MATERIAL I EMPLACEMENT METIICID&.L11OUNT
Dlrrigation 'ft. ft.
Nou . rSupplyRell:-Wte 'ft. ft,
_. .
DMonitoring DRctim'ery -• • - - --
Injection Well: ft. ft.
DAgttifcrRecharge • DGrouridwatcrRentcdiatiou •istisANDJGRAVEL-I!ACK'lltitufleabtn) .
'FROM to . 1MATI:RIA1. • F:IPIACEMENT METHOD
ElAgniferStorage and Rccoveiy. ❑Salinity Harrier R. R.
lJArjnifcr Test. ❑Stonnwtatcr Dr.Iittagc - '
. fi.. (t.
OE: r:rinicntat TcLlrnology DSitbsidcnce(.:onrol .
20.'DRILL1NG'LOG(nttueh additional sheets-if itiecisa n'1 .
OGeodtenntl(Closed Loup) OTr.rcer MOAT- TO DtssCRuPTION(whr.Unnlnwa,yiIZ ithhpt.t 1u i'..ak',1
❑G themttai(heating Coollie Return} ®011ter(explain under#21 Retn nks) .ft.. ft.
rt. tL I s r.. ,�
4.Date Well(s)Completed: 5/19/23 Well l IP-1 - IP-32 (Even erslt. R E-c ; N�
54.Well Meatball t
ft.. ft JU1V -' 2023
Robbin Heights Grocery . . ft. . ft.
• Facilrl 1•On•ner.Naruc . Facility Ink(iE Iicable), )getc;nRelej aPP. ft, ft. 471 1�f.a Y�Utlk
• ll►
503 E. 7th Ave., Raeford; NC, 28376 ft. ft,
Plnsieul Address.Cit}:.:rod Zip ' -2f:RLM'tfhS - . . .
Hoke OPT injections through drill rods
Count} saute)ld•_nlifiediut No,(PIN)
Sb. ittitudc and I.onglt
L tulc in degrees/minutof.steonds or dceimal ttegrccs: 22.Certification:
of non lieu,ow)oblong is srdlickad)
N W • _ __ • 5/30/2023
Sieuvt ofCc.;ifcdWellContractor Dajc
G.Is(are)the 1t'NII(s)t OPenn utent or SlTeutporary ity Aigrrhrg rhir Pram,I hereby e'trfifv fl);:i 14.u'elt's)him(ni na)c'ors'rruerer!Sir frceorrlmrcr
rilrh(5.1 NCAC 02C,O1(M nr LTA NCAC 02 C.0204)Weil C'oeatrorrinn Staradcrrtls mid:bar er
7.Isthisarepairtoanexistingwell: DVtu or iitiNo earr.of day rrrtioJhiisih:cnpmridedrau:'r.,rd?rin'tia•r.
if rh(s.11 a rip*.fag rorr kooiwa well mnuci a,,-blfarrnrrrima aid e in'abt the nrarrare office
rr.pcir rurrlrr 14V'remarks secuun or rm the bark Of this form 23.Site diagram or additional well details:
You may use the back of this pilge to.pros'ide additional well site details:or Well
S.Nuuther of wells couatratcted: 16 -construction details, You may also attach additional pages if necessaly.
For aunlrlple anferrion crarur-rarer 1uppJa-wells ONLY with the sends colesrrietriwt,yora eno
submit law form. SUIIDi1TTAL iNSTUCTiONS
9.Total Well depth below land surface: 32 (It.) 2da. For All Wells: Submit this form within 30 days of completion of well
For iiwirlpk:cells lisr all depths(fdi,sii'rent(e aa!p(t'-3€.24100'and:2€./0.9) constntction to Rite Cotton rig:
10.Static water level below top of casing ((I,) Division of Water Resources,Information Processing Unit,
Owe,level&:'Lure rua(ra„.case'+" 1617 Mail Service Center,Raleigh,.NC 27699-1617
11,Borehole diameter:2.25" (in.) 24b;For Injection Weill ONLY: ,in!addition to.sending.tite farm to the address in
24a above,also submit a copy of(his fort within 30 days of completion of w ll
12.Well construction method: DPT cons uctiom tothe Iollowine.:-
(i.e.auger,minty,cubic dirccl push etc.)
_ -_ . Divisionof Water Resources,Underground Injection Control Prognun,
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Service Center.Raleigh,NC 27699-1636
13;p Yield(�gfnl) Method ofhSt 24e.,For Water Supply.&Inlection�.WeLls:
- Also subiiit one copy of this form Within 30.days ofcompletion.of
13b,Disinfection qpc: Amount:
well constnrclion.to the county health deportment or the county where
constnictcd.
Farm GW-1 Nome Carolina Department of Erv'in:tuncio and Natural Resources-Division of Water Rmotrct Revised August 2013