GW1--01332_Well Construction - GW1_20240304

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WELL CONSTRUCTION'RECORD For formal Use ONLY.;
This form can be used for single or tmiltipk Wells
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I.WellContrtctor Inforuation:
;I1:WATER ZONES . 1
Tyler Brown . . - FROM. TO DFSr'RIFTION -
WeIl CorsngorName ft.. R. I
4625A :ft. IL I.
NC WelI Can)raclorCcrtifrcatiori Nmiiier • • :IS:OUTER CASiiVG(For.-mufti-cased nci1sl'OR LINER(if'an`ticabi
FTiOM TO : - DIAMETER.I TIiCKA'ESS. MATERIAL•
SAEDACCO 0 ft.. 19.5 rt.. 2 hi.• SCH-40 PVC
Corivuty Nano: ,t6i INNER CASING OR TUBING(geolbernfal doseddonp)•
-FROM - 70 DLLIIETER• I THICKNESS MATERIAL
2.W ell Construction Pernut#: ft, • It-. at:m .
List afialyilfcable rsrUpanoits,(ie.County;Swath.•.Variance..0 a rico etc.)
-rt. ft. .In.
3.Wc1l.Use(chc&*cii ace).: 17:SCREEN.
WaterSuppl♦Well; FROM'. TO DIAMETER SLOT Sin TiIlCKN}NS 1 MATERIAL
19.5ft. 39.5 ft. 2 is i:010 SCH-40 • PVC
DAgrieult(iral ❑MunidipalrFublic • .
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. DGeothermal(HeatingZeoting Supply) ®Residential Water Supply(single)
'It. f6 In. 1'
DlndusttiaUConlntercial ®Residential WaterSupply(stared) •.m:GROUT• _
FROSt . . TO . MATERIAL , EMPrACESIENT 3rEtrtOD&AMOUNT
II Irrigation - . . . . 0 ft. 13.5 •ft. Bentonite c e
'Non-Water Suply Well:•
n.. ft. .
',Monitoring . DRcco}rry. •
Injection Welts . - R. . ft. . .
' CIAgnifcrRccieirgd' • DGiouridwalcrRcntcdiation ' 19.SANDIGRAVEL•PACK(ifappiiubl01"-
FROM " TO MATKRIA I. • EMPi,%CI:lENTMISnOn '
1 Agnifcr.Storage and Itcco cty . °Salinity Ranier, ' • 17.5 R. 39.5 ft. Gravel pack #2
❑AguiifcrTest DStonmratcri}miirage fa R.
• 17Ekperimcntal Technology ['Subsidence Control .. •
•2a:DRILLiNG•I:OG(altach-addiliorial'sheets if accessary!
°Geothenml(Closed Loop) OTracer FROM TO DESCRIPTION(cobr.lmnitletli wn'nkk rf it,Wain NW..du l
❑Creothenuat(Heating(Caoliug Remit) °Outer(explain under#21•Retunrks) . •R- ft.. • I`
ft.. - ft. . I • . .
• 4.Date Well(s)Completed:'2-14-24 • Well ID#MW-5. -„
• ft. R. -1-'.''� , i ! D
3��Piti:i
5a:Wt.41 Location: R,• h.
Kayser Roth It, II. �)Af� p Zp q . .
Facilit}•;Diyn rNan>c• Facility DM)(ifappli:ablc) R. ' - ft,- .
h1iBr2'1 iC t .'...„,,
714 1-40, Graham, NC,.27253 R. ft,. I .r- •94unit
PlastealAddress City.and Zip•• ;21:R.MARKS
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Alamance Bentonite seal. 13.5r-17.5r,
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Calmly Pareel ldeoliftcation No,(P1N► - -
5b.!.ittilade and longitude in 6epees/minutes/Seconds or deehaoal degrees 22.Ccrtifieatioa: .
(it cell field,one1 W7o is strl(itI ttl}
. N W 2/15/2624 .
' Slgrutu.:ofCeitiftedWell Contractor• I - .Dale
6.Is(are)the wcli(s): )!Permanent or °Temporary I
ily signing ilia farm;1 here-by certify that Au!!Eellfs)was(paver renyinrcred br;acrordrmce
with 15A NCAC 02C..0100 or 1 SA NOW'PlC.0200{IWI Consrroaiar Standards and thor a
7,Is this a repair to an existing well: DYcv or ffiNo 'ropy of Mir record bas,been Provided tours.nrll miner.
• lf;Ns'Is a repair:fill pat knoilir.trrld cnmytucreoa&fomtar'on anti explain the aortae of the
repair aadcr1121 ion arkssceiimr or on Arc bark of this form. 23.Site diagram or additional well details; -
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. You may use the back of this page to priiOide additional well site details or welt
• 8.Number of wells cons-tlticted: 1 cotrsintctiondelaiis. You inay'also attach additional pages if necessary: •
Far IIW1Ilplc;feel;on or nail-irarer suppA-wits ONLY trhh ttr sameconsrruction,jou can
salmis one form. . - SUBMITTAL iNSTITCTIONS I.
9.Total well depth below land surface: 39.5 (ft.) 21a.-Far All Wells: Submit this fon r within 30.days of'completion of welt
For mairlpic wvUslist aft depths lfdi,(,"event(crag nrs-3@200'and 10100) • eonstntction to the following; I.
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• 10.Static water level below nip of easing: • .(f ) DiviSiun of Water Resources;Information Processing Unit,
1fnwrer level is strove cadet,:ate"+" 1617 Mail Senicc Colter,Raleigh,NC 27659=1617
•11.Borehole diaiticten 6" . '(in.) • 24b.For luilection Wells ONLY: in addition to sending the form to the address-in
.24aabove.also submit a copy of this fame within 30 day's'of.completion.of well
12.Well ednstvuctiou method:Rote-sonic construction to the following:
(ie:auger.rotary.table.direct push etc.)
Disision of Water Resources,Underground Injection Control Pr grans.
FOR WATER SUPPLY WELLS ONLY: 1636 NUR Service Centc I Raleigh,NC27699-1636
2d
13 o Yield(glim) Method of test: c.-Foi Water Supply&fnjectfon Wells:;
• Also submit one copy'of this fouu within 30 days of completion.of
13h.Disinfection type:. Amount: well constriction to the calmly health c)iaiiment of the.comly.whcre
• - constructed.
• •Fann GW-L North Carolina Departs. tent of Eneiraruwu and Natural Resources—Division of'Water'Rmo - Revised AtgustYU13