GW1--01331_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD For Internal UseONLY:
This form can be used for single or,tnuhipk wells' '
1.Wdl Contractor Information:
arleWATER ZONES
Tyler'Brown - FROM TO • 1-DESCRIPTION'' '
Well ConitadorName R. ft,
4625A ft. ft.
NC Well Conlractar Con ificntionNunilict AS.OUTER CASING(finemulls-ra'acdrictls)ORLINERWan'ticat:el
•FROM TO . DIAMETER.I T ICK)TSS- MATERIAL•
SAEDACCO • -0 ft., 13 It. -2 M.• SCH-40 PVC
Company NameI6.INNER CASING OR TUBING(�,eoibcrtisat elosed4oup). .: '
.. -FROM . To - DIAMETER. THICKNESS MATERIAL . -
2.Well Construction Permit#: . - . R. • R. in- .
fast all will permits(cc.Conn%Smt¢;.Variarrc,hfB11C►eir..) - . • -
14 ft,- in.`
3.Welt,tyse(check:hell use): ra:Si:R>i eN
' Water Supply Well: • most TO . 'DIAMETER •SLOT stn. THIICKNESS. MATERIAt,
Clflgetcultltral ®hllmiClpaUlEltbhc 13 rt. 28• :fit: 2- 'ill '.010 SCE-90 PVC
CIGeothe anal(HeatingiCaoling Supply). ®Residential Water Supply(single) ft. • (L. - in, 1
DlndusirialfConmtcrcial . ClResidenual Water Supply(slrtted) •=t9:GRotrr
teROM• ' TO. - .MATERIAL ,. - EMPACEMENTSr6TiiOD&AMOUNT
Elirtipation . . " . • 0 ' ' .R. 7 'ft. Bentonite c nt
Non-Water Supply Well; . . =
• rt.. ft, •
Monitoring _ - . . PRccoymy '
•Injedion:Welt: - . . rt. •fit.
ClAgwifcrl;cchargc t 7Ginundwalcr Rcntcdiation ASL SANDIGRAVEL PACK fir rgqdieabte) - •
' ' • FROM TO • • 'M TERIAI, ' 'E.MPLtCE:MENTMETHOD - '
CJAi(nifcr Storage and Recovery. ElSalinity Hamer - • 11 •ft. 28 ft.. Gravel pack #2
EI Agnifcr Test.. m C1Sivm uct Urtinaae• -R. ft..
❑Experimental Technology CDSabsidcncc Genteel V
• 20:DRILLING'I:OG(unacb:addltioanl cheers if accessary,DGeotliennal(Ctosed Loop) • DTracer. .FROM .TO DESCRIPTION(C»br.hackled.vdLMkk not.osip vm.do.)
UGcotteuual(Heating(Cao1ue Return) .-130111er(explain under#21 Retliarls) 'rt. • - fu
ft.. rt.
4.Date Well(s)Completed;•2-14-24 Well m#144173 i. '.
• (t. ft.
Sa.Well Location: • • .ft. fits U. +- '""
Kayser Roth rt.: ft. 6 ,�
, •
Factlit Oimm•Nmae Facility ilk(ifappli abic) R. ft.
714 I-40, Graham, NC;.27253 ' R, ft.'
. • Pl'sisal Address.City.andZip• ,IL:.p.4.'/A .S` ,1iliArfiis:IC:1 PMC300:f:;un
• Alarnance Bentonite seal 7'-11' . • Cl?1/G'rl0t'}
County • parcel IdeulitKatiou No,(PIN)
• Sb.Kaittifadcand Longitude in degrees/minutestsecrinds or decuital degrees:
(ifssell field,one t at/long Is softie teul) 22.CctTitication: .
. l� • W ,/E % ! 2/15/2024
• • Sig:OM::ofCcitifcd Well Contractor I , Date
6.Is.(are)the ri'ell(s)t.SlPermanent or 1]Temporat}' 4:signilig this form,'1 kcabs nprrifr char the nett{s•J wax('Mere)cx irmrcred Jrr axxmtkniv
' with IM NOW 02C,0100 or 1st NC1C Co;0200 Well Consrrtcrlon St airdards and char a
7.1ss this a repair toanexistingwell; ']Yes or RIND sapirof Mir word hos Nor provident to din%lrll(Mawr,
(M its'L.a rrpalr,fill oat kovirva well carannrcrton lnfomaeslon and explain Or nitrate of ncc.
repairthrderdt2l remarks sactimr or in the hark i f this•form 23.Site:diagram or additional well defitils:
You may use the back of this page to pros ide additional well site detail';or welt
•
S.Number of wells constructed: 1 • cotlstlletioa details. You May also attack additional pages if necessary.
For malrople lrifccrlo)!Brnon-water supple wells ONLY Ira to santecmotruiriou,von can '
submit'one form. SUBMITTALINSTLTCTIONS r ,
9.dotal well depth below land surface; 28 ' . OM .24a. Fur Ali Wells:. Snhtmt this•font within 30 days of completion of well -- •
-For mnhlpJc irellsllstalldeprhr Ifdif rant rracrpf.3@700'anrt 20i00) • construction to the followingg;.
• ➢0.Static water revel below lap of eaehlgi - • •((i.) Division of Water Resources,Information Psnc sing Unit,
if water level is abate casfag;ure.•'t" 1617 MaiiService Center,Raleigh,NC 27.699 l-6L7
II.Borehole diameter:6" . -S-(in.) 24b.For Infection Wells ONLY: in addition to sending the font to the address-in
24a above.also submit a copy of this foitn within 30 days"of completion of well
12.Well construction method:Rote-sonic construction to the following:' 1
Ile:auger.rotary.cable,direct paste cue.) ' .
• 'Division of Water Resources;Uadergtvuud Injecilou•Coutrol Program;
FOR WATER SUPPLY WELLS ONLY:. •
. • 1636 Milt Service Cente I,Raleigh,NC 27499.1636
13a Yield lte.'For Water Supply 1*Injection Wells;
(>pm) Aicttod oftcst: Also submit one copy of-this form within 30,daysofeompletionof
13h.Disinfct tiun type:. • Amount: . well cousintctian to the county health del anment of the.couuiy.whcro
constructed. .
. I
Forni GW-t Nonh Caraltna Dcpaeritcni of Envirinnsaii and Natural Resources-D,tvirlon of WaterRmotrem: Revised Atgust.i0l3