GW1--05808_Well Construction - GW1_20230912

1 ,
WELL CONSTRUCTION RECORD Far itecmal rise ONLY:
T s faun can be used for Single or multiple wells /\ I
1.4Pe11.Contracto>r Information: 1\
1l::3lATERZON1S .•- - n
Chris Buffer. FROM. TO of•CRIPt1olt '
Well Coraractor Name- ft. rt. I
4223-A . • ft. fG
NC Wc1I Contractor C}criftvtionNutrllet ;`&.OUTEft-CASING'((ui-mu111-!jad i-crI 1'OR LINER•(it-air 11biti it, .-
FROM TO MANIETRR IIIIC ISE MATERIAL • 1
SAEDACCO ft, (I.' la
Conitiald-Nau - :•,16 NNER.CASING'ORTIMING`tgt►oi6cim:il'etiocd-toaj t.. .:-
FAO51 . ,TO DIAMETER THICKNESS MATERIAL
2.Will ll Construction Permit 4; 0 ft. 16 It.• 2 ; 'bi SCH-40 PVC
lisi011 5,11rabfe rsc1lpeamit.(cr,.Comuy.:V&A Variant-T.IgfettiCi;etc.)
ft.• ft. - tn, .
3.40c1)_Use(char:Well rase); 17:S(itEt N
Water Supply Welk • FttOSI. TO D IIETt LW'
:SLOTSt?.E T111C7rY RtiS' I 5iAT6 RiAt.
DAgfi ul[tlral CllvltlnicipallPubliC. 16 ft. 26 ff 2 hi! .010 SCH-40 PVC
®Creatltennat(Heating/Cooling•Supply) ©Residential Water Supjily(single) f i', f' in'
12IRdustrial/Commercial • ©Residential Water Supply'(shared) 'FRo GROUT;..., . .-. $'
FR05f TO. 1LkT&ItL1L EMPLACEMENT METHOD 1:Ahmitmrr
Dtnipation- - 0 'ft. 13 ft.' -Portland Pour
Non-Water Supply Well: • . .. . . .
NOvionitoting DEtccowry _ .. ft
Injection Welt: ft. • ft,
• CIrlgaifer'Rccharge • C lOmundwatcrlteiitcdiatfou - 19 JC SMNDIIAVELPACI(°iiralyalcnbte)7•"- --- -=- - . T.- ; — -=- -.- . , • ---- ,
FRO5I 10 1 stAtta IAI, EIIPIr1crmfot sii:I'rrnn -
, ❑Ailnifcr-Sloragc and Rceovety OSalinity Harrier 15 It. '27 h. Sand I' ' #2
ElArtnit rTest. DS(OORNalcr T..,litingc .
. R.. ft: 1: '
DE erimcntal Tcrlinotogy AStrbsidcncc Control • "1I.DRIL G�L1NLOG(iiliactiadalionalalicetsIf-"ucir nrv3. ' _ •
OGeotltemral(ClosedLoop) t'7Traeer. FROM 10 DESCRIPTION(o)krliunlncn.ua nicknot:grainsic.caul
t-IGeotltetmal(Heating/Cooling'Return) OOtller.(explain under i121 Retuatks) ft, f4 1 •
ft. It.
4.Date'Ye1(s).Completed: 8-14-2023 NVeIIID#Ica-5R 'ft. See Gip' Notes
Sit;'MilI .ft. ft. - `'L-
owland: 1..I V17
6
Holcomb Creosote.Site . . . . ft.. "IL- ' �p � q q �y,
.. ` '
FacilifyrOnncrNnruc Facility!bl(fapplicablc) -~ �+-L-�C�—
R. (t
5016 US Hwy 601, Yadkinville, NC, 27005 , ft, ft. ' h .,.tr a.-II P .any, Lr)f
Pltt-sirul Address.City:and Zip 13tA:r^t a.3
2v.-REMARKS: .
Yadkin Bentonite seal from 13-15'
County Parcel t k111iltcai qu No,(PIN)
Sb,I.atifude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(itxell rei4,one latItetiis'sultihkrd)
.
N W Chris Ruff- er- ; 8/20/2023
Sigrntur,.afccnificd Via Cantnnctar i Daic
6:Is(a e)the well(s): 59Perntanent .or CITemporary
fay sighing liras.fttirmi lrereby cerru'y rhoi flag ndlfs)tsar O em)anis::meted in,nt orrtmtar
With/Set NOW 02C.01(M d'r I5A NCt1G-O2C:O200 Well Consrrnc,fat Standards and Oka a
7.Is this a repair to an existing w cli! 2 1Ye or DNr1, cqkr.oirrar ieriirri hsS t)esn provided ra th'47 argil owner.
if thls:ira rei air.fail e.lir Jwllw wdI naruttuctiori ht oromnlat Mil ti plain the otrtrore of the 1.. -
repair ruder F21"rroutrkssirtrua ei-iw the brick.-Of this fonu . 23:Site.±!rout•ent or,udditiounI welt details:
You may use tub back of this page to provide addiyonat well site.details.or Well
8.Nrnither'of Wells constr•tteted: 1 -construction details. You may also a11acll additional pages if-necessary.
For rnnlriplc lutfeerlon or aott-nearer supply wells ONLY ai Jrh thc.same cog strurriou,-you can '
sulrma tyre form. SUBMITTAL INSTUCTIONS
1
9.Total welt depth liefoiw laud surface: 27' (ft.) 241 For All Wells: Submit this form within 311 days of comptetion of well
For iuhi*iir1Islisr Oil drprhsifdi, •rent(cranple-•3@@?(O'and.20100'1 Constn.ctiontothetoitoniag:
•
10.Static water level below.top of easing;: (IY,) Bivisirin of tauter Resuu rocs,Information Ftneessing Unit,.
1f utter kit!Js'ithoee cnaing,rase•"+" 1617 hiaiLSeryicc Center,Raleigh,NC 276 9 9-1 6 17
11.Borehole diameter: . (in,) 24b;For Infection Wells ONLY: I+r: n addition to-sending the fowl to the ddress in
24aabove.also submit a-copy of this'fomt within-30'days'of completi u of dell
12.Well construction method: Sonic construction to the following-• 1
(i.e.auger,ireuy,cable,direct posh;etc.) • I,
Division of Water-Resouroes,Underground injection Control.Pro.g-ant,
FOR WATER SUPPLY WELLS ONLY::. - - - 1636 Mail Service Center,Raleigh,NC 276994636 •
13;t,1R'icld(glint) Method of test: 22�For Water Supply.lit Injection•Weals:
Also submit one Copy of[Ids fdinllwithitl 30,days of completion of
13b.Disinfection t%p: Amount: well can5ttlrcti0n to the county health'department of'the carroty where
- constructed. I ,
• I
• Form GIV-1 Nonh Carolina Depanmrnt.of Environment and Natural Resources-Division of Water Retrom Revised August 2013