GW1--02143_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD • .. - •
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This farm can be used for'single cir multiple wells• '
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1.Well COntraCtor Inforivalion: A
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Robert Miller' . . . . FROM .10 "DESCRIMION _ '
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. ,ell Column Name • , ft,• fr... I. . . .
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. IL 2675—A ft..' . .
' • NC Well Col:trader Catificittithi NIllita ' . ' V EK OUTER CASING Kor-atutikisetliiellsi OR LINER ilf-eli Weiler.
• • PROM I TO ' ; DIAMETER I C THICENT.SS. MATERIAL•
SAEDACCO ' 0 .ft.] 30 . it• 2. . l•IO. sc.rt-40 . - PVC
C011iflally rianiC • . - 16.1NNER CASING OR TUBING .adhering ekised-lou
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PROM . TO• DLAMETER I IIIICKNESS MATERIAL
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• 2.Writ Construction Peivnit if: _• - . . . . . .. • -'ft. -.. . It.' . • i ; . '•
Um ail aRylicark well permits.fiie.t'aunry;.5Varkrirce..kjetti4 ere4 :ft • - ., . •
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3.1V0E.Lik(OttpekiValtl.Sej; ' 17:SCREEN ' • •. . .
• ' Water Supply Welt ' •• - . F10.01'.• 10 •DIAMETER StOT SIZE IIIICKNISS MATERIAL , •
' 'lit- . .010 SCR 40. •
. . ClAgrietiltural LIMunidipal/Publie- 30 R. ,90 'ft. 2 PVC • .
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C3Geolltetmal(lleatingittioling Supply} E2Residential Water Supply( . ft.single) IR, 1 -
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CI Industrial/Commercial . °Residential Water Supply(shared) - '.-
Zost•-°131:. TG . :MATERIAL I: 7 EiMPLACESILITMEMOD.4 ASIOUN T . .
' . 17 kiigation •. . . . . . . : 0 ' R.. 25 -•It Porrlarict pour
Nou-Watee Supply W Iell; - • • •
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Monitoring . ' 0Rocoyely ' , . : . ft
Injection:Well: . . • , -ft,• .-ft: . . ,"• . . .
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. CiAtiniferDcchirge •• ClUtutititirraier ReniediOlicin• •1.9.-SANINGILWEL•PACK Of applicabter- . - - .. . -..: .. . . • - .
-vitOst-- • 10• - - NUTT:RIM.I • . ' v.mpLactsnorr m rtnon " •
PAiptiferStrouge and Recovery 1:1alinitY Elarrici. • 27 .11,- 40 ft. Silica,sand • 20/30
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DAmilfer Test. . . CIStomnratcr Drairo&- . • 'ft. . 'ft. .• ,.d. • . . ,. ' '. _ . . .
• - OEVcrilliclilid Tcci#1010g • 0$obsideneetentrol - • , ..,
AO:,DRILLING 1:0G(attach iidditioiratilieek,if necessurct .•
'. ClCoothetinal(Closed tool)) . CITracer. • . • . FROM ' .70 - ! DESCRIPTION(obi'.hArdnert.titiVnick D po.trel.c.kre.riot' •
LIGeothettnal illeatineiCtioling Return) . 130ther(explain under.42 1 Rematirs) .0 - !rt tan sl(Lt( sand
ft.. . . •. .ft. • - I..11 . . - • . •
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4.1Dotewetioco!,ipided-,-3-12-24 wen Higtor-1. - • - • •_ft. ft... I 11• : "-:.;—.,---'.1• • . ' .
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So.Well Locaion: ft. ' rt.-• I
, '• .S.,,•L•.;.t.'irr.
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Wieland Copper. • -ft. - .ft, : IT . '1 ')'
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. ' Factlity,s0inurnutio . i" Facility MO(if4ppliFable) •
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' 3990 US-311 , PinaHall, WC; 27042 . . . . .ft• • IL • • , l'! I' . •:('-'--•;—,1'."':--ir.f.Z.Iri:!-:-1-.-
PllYtiall AgrFis CIEF7-an42113: =-2E.REALtlifiS . i •
. - . Stokes -- • • . . . , . . • .2' bentonite seal from 251to 27' '. . .
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Cougy .Ntecl Ideutificattott No.(PIN) • 2
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h.,Whit de and Longitude in.itegrecsftninutes/.secOnds or decimal • 2/ Cerlifir.ation:', 1 . • ,
(frOoll fieklionelatacoh.lr sollichft ..
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' • - ' 3/18/2024
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• - . Sigmtutc.Ofifcc .c..o -;17•E-...:2,1‘s,...o:,:•
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. 6.I.s.(are),the well0): 8]Pennanent or Dtemporary ftiotglihrg thpr form:1i iterchy certify that'the well(s)tsTis(yiri:t...)cy.rnorarcted tir trc..eurderrice•
. with'15ANCAC 02C.0109 ar 1511 NCrte 02C.0200 We•ilCairstmetiort Standards and the:a
7.Is this a repair In an4iatigg wcil! . . OWN .iir 111No copy'of Mir rceoiY1 has Ocy,proyirrerl,6 i'Ake iirli ont7rer, • . - '
i IIf;#1511: a irpokifill oar kruiiiii well corminrcriatrialannation awl explain th a e ware of the . • - ' ,
repair wrder 412.1 remarks.ircihin.cii-on rhe brick of thi.r krin. ' • -• 23.Site rliagram'or additioind will derails: .
You may use the,back of this page to pros ide additional well site details or.Welt
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• 8.Number of Wells cousinic&d: 1 ,. . . consttuetioWdelaiIi, You ittay alto attach additional pages if necesSaty. . •
For ittiiltOpi,e lofeeliou or nott-yam.siippkwrift ONLY'with the same. consirmillon pat, CO
strhuilronif fomr.' ' - '• . . SLIBM11tAL INSTiTCTIoN8. ! .
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9.Total well,depih betoii-hind surfic-e: 40 - • (1,) 24a. For All Wells: 'Submit this-fano ivithin 30•days of'completiou of welt
For oodriplc i;•ellslist all rfepths if diOiyent:(exam&-3€100'aid 2@leg) . - constmetionto 010(ollowing: ,
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1(1.Static water level below tap of casingi• -(ft.) Division of Water Resources,Information Processing Unit, •
' If welter:level is ilhoei eastaxiise"4:" ' . - . 1617 Mad Service Cenier,Raleigh,NC 2769!)I617. -.
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11.Borehole diameter:8 r 257 • . •-.0.n.) - 21b.Far I:election Wells ONLY:.pi!addition to sending the feint to the.address-in
•21a above,also submit a copy of this funs within 30 dais of.completion.,of well
1.7...We.11 c_OnSt. uctiou Meth,od $SA ' •
' dtslnitiOt to the foLoWing . .
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:3(Lc; 10131y,agile,dirett pdsk etc.)
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'Division of Water Resources,Underground injection•Gintrot Program,
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FOR WATER SUPPLY WELLS ONLY: ' ' . ' • • ' - :1630 Wit Service cdnier.Raleigh,NC 27699-1636
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• 24e.14ii-Watce Soptdv&Injection'Welts: . .
14a.IIield(gpm) Method-of test: •
- - Also'subtnit one coPy'of this Rini,:-)Vithitt,30:days of completion of • .
13b.Disinfection type • - Amount: •. well constriction Co the calmly health department of the.comiteWhere
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constmcted.
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FonnGW-1 . North Carolina Department of EIR'ilDIVIrIll and Nautral Resources—ftivision of Water RdoLa1ces- . Revised Augmt2OLI
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