GW1--01444_Well Construction - GW1_20240301

1
WELL CONSTRUCTION RECORD For[Mental Usc ONLY:
This form can be used for single ar(multiple wells
I.Well Contractor Information:
14.,WATLRZONES . t .'. . . . .
Rich Lemire . FROM '10 • lESCRIPIION.
Well CpeaiaOor Name ft, ft., I j
.fr. iL I I
' 2593A
NC Well CanlracldrCcniftcaionNwttrcr a5.'O(ITER CASING-an reinhknsiiI"isdis)'ORLINER(11att ticobk): '
• FnoNr m mAdrr.Tt R T1ucKNrss NtATtsnrAt.
SAEDACCO IL. rt. la
Campion-Name 16.1NNERCASING OR TUBING(.,thermal etasedaoop.•.". _
FROM TO ' DIAMETER TiICKNESS NIAT'ERIAL 1
2.Well Constiuctinn Permit it: 0 ft, 14 . it: 2 ''I L SCH-40 PVC
11u all alp lIertbfc rcril penults(Lr.County.Ave,.t'ariarsr.Ilectiat rir..)
ft. . A, !la.
3.Welt Use(cheek well use): • ` t9 5CN1 EN
.,WaterSupph'Went Fn0NW" . TO .Dt.METER SLOT SPX TIIICKNISS i NIATP.NtaL
❑Agricultural ❑MutucipatiPttbiuc 14 ft. 34 ft, 2 •in 010 SCH-90 9 PVC
❑Deothe utat(HcatingiCooling Supply) ❑Resideutial Water Supply(single) f6 fL rn. .. I
DtndusiriallConn iercial ©Residential Water Supply(sliced) -no`ROtFf To .. MATERIAL • EMPLICE,NIENT METHOD&AMOUNT
❑irrigation . 0 it. 10 ft. PORTLAND POURED
Non Water Supply Well:. R. fa
°Monitoring • . O �'RCetnr . - '
Inject Ion'Welt: n'' ft.•
°Aquifer Recharge ElOtoundwatcrRcnicdiation t9 SANDIGRAVELBACK(lfappliubte) ..:. _
'FROM TO • NA•tRRttI, ' t?NlP1.ACEMENTmrstiOn
°Agn(fcr.Storage and Rccovcty °Salinity Barrier 12 R. 34 It. SAND #2
°AgliiferTcst °SiommtstcrDrtinage ft. fe .
ElEipctimcnial Technology ❑Sltbsidence Coltptol
•10:DRiLLIA'G'LOGfntlach nddltionidsticels irltccessar,•t ' .
❑Geothermal(Closed Loop) ❑Tlacer, Rost-• TO DI;SCItIPilON holm,.minium.,n n'rocktrtra t rsin ritc.rita
❑Geotketinal(Heatiug'Coollmg Return) -•❑Other(esploit under 1121 Reuiaiksl 0 iL 25 rt. BACK FILL
25 ft. 34 ft. PWR i,
4.Date Well(s)Completed; 1-18-2024 well IDli8z-4W . . iG ,_._C,,,,, + ,M'
5a,Will Location: '``e" € V 1
iL i4
Toyota rt. ft, , MAR 0 1 2024
Facilit)•,tDisocr:Niutte .Facility►Dk(itapplkablc) R. fl. I '
5938. Julian Airport Rd., Liberty, NC, 27298 ft. iI, _ �fQlBOG
Plu slat Address.City.and Zip :.21:REMARKS ,
Randolph BENTONITE FROM 10' TO 121'.,
Ccuwty. Parcel kloilifrcalian No,(PIN)
Sh.l ttftirde acid Longitude in degrceslminutcs,'Neconds or decimal degrees: 22.CcitifeaNnn:
((fools tick!,one lat./long is suflieteid) •
N W 'Y �' t/1', �rvAt%..i. _ ' 1/20/2024
• Sioaitureofb. Well eentractar Pale
6.Is(are)the well(s):.SlPerinauent .Or DTcmporaty
!lF signingltrir form,I herebyrerrel.'duo rlie ue1lfs)was ft,rrrl cvn_rrructer!!n acrotrhmcx•
frith lM NOW 02C,0107 or 15A NC4C102C,0200 WW1 Constrnrrtar Standards and rhos a
7.Ls this a repairto an existing well: ' i7Yes or Elio eo•iyofrhlr record has bt ro pror•;rhd tit r well owner.
if th(sis a repair,felt art/(emit well coaatualon luforrrurrion and explain the tytrare of the
repair under d21 FcaarfaSe time or on the hart of(fir form. • 23.Site dhigram or additional well'details:
You-may use the back of this page to provide additional well site details or welt
8.Number of wells constricted: 1 cousftuctiou details. You may also attach additional pages if necessary.
For tituitiple iueerhnn or ntta-water supply reeds ONLY with the strata cmrstrurflou,you eelo '
.sahmir'encIona. - SUBMITTAL INSTUCTIONS I'
9.Total well depth below Laud surface: 34 (ft,) 24a..For All Wells: Submit this form within 30 days of completion of well
For multiple Ives list di depths ifdifferent(crmnpte-30200'atul 2@ I00') Constnrction to the following;
10.Static water level below tap of casing: 25 -(ft.) Dh i ien of Water Resources,Information Processing Unit,
if wilier level is above cnsUtx:sue.'•+" 1617 Mail Service Center,Raleigh,NC 27699-1G17
11,Burchote diameter:8.25" (in.) 24b.For Infection Weila ONLY: In addition to sending the four to the address in
24a above.also submit a copy of this form within 30 days of completion of well
12.Well construction method:NSA eelISImctfon to the following: I,
(i.c.auger.rotary,table.(Erect risk etc.) I
Division of Water Resources,Underground Injection-Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 ALAI Service Cc(ntcr.Raleigh,NC 27699.1636
131 Yield(gttnt) _ Method of test: 24e. er-Water Snpuilv&Ini ction:Wett_s:
Also submit one copy of this form Within 30 days of completion of
13b.Disinfection type: ' Amount: west construction to the county Health department of the coutrtv.where
constructed.
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' Fano OW-1 North Carolina 0.parinteio of Endroruikm awl Natural Resources-Division of Water Reso.rtm Revised Atigtait'to 13