GW1--02623_Well Construction - GW1_20240501

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WELL CONSTRUCTION RECORD . 0\i\..../ . FOr Normal VsepNLy:, • ' - . • . •
This form can IN used for Shies&tualtilik wells•. .
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1.Well Contractor InforMation:
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'14:-WATER ZONES
' Stefan Smith . . . ' PIWIt1 ' TO • • IOSCRIPTION
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Well CtininintorNarm: ' .11,' rt.. . .
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3576A . ..
NC Well Contractor Ccrtiftealion Nmilter , . .
. . 15.1".1UTERCASING(firrirurl11-OiseilifirlsTOR-LINER ill nit IlltiabieV • - - "
FROM To ' " otANIF,TER.-• TrlatliNTss- J,NIATTIOAt. __•_ .
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SAEDACCO . . 0- ft:. 4 IL -2" •• hi.•' SCH-40 • PVC •
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Company hi:low . ' ' 16;"INNER CASING OR TUBING(geothennaldosed-loop). - •
. . . ,•FRom • TO MASIETER I IIIICKNESS MATERIAL
. - . 2.Will.Construction Permit#: . . " . . . . . . 'ft. . ft. ' -61. ,
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List oflopigio.dtle weifpennfirfie.Cnurthy;3Isrt 1,th-far:re.try-action ex:). .
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. 1.Well:Use(ehgelt well 0$0j.:- . • - t7:SCREEN • •
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. -. Water Supply Well:. • -• - . FROM . TO .•DIAMETER 'SLOT SIM Ill ICKN ISS 1 SIATERI A L• .
.. . • ' 4 • ft. 14 .•ft. 2" ••in; .''.010 SCH-40 PVC . . •
.• .1:1Agieultur01 • . ElMtinidipaliPublie .
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•R. FL -io. . .
. . . 1:1Geothermal(icatingiCoOling Supply) . DResidentiat Water Supply(single) • . • ,
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. • .ClIndusttialfConmtercial • C3Residential Water Supply(shar ied) • .1 . . •
o • '.MATERIAL. ' EMPLACESIENT•3IETIIOD.4 AMOUNT' •
0 lthinatioti . . .
. • 0 It. 2 ft. Portland; Pour . .
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Non-Watei Supply Well: ft
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ilionitorill8 • . " . " . .1:1Recovery . .. ' " •
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• • Injection-Well: . ' . . . . . -..-ft.. -ft. - ' ; . . . -. . .
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Cl"Aquifer Recharge •• 1:36i0titidwater Reniediation 49....SANDiGRAVEL,PACK Of applieabrer- - -. . . .-- .. - • , •
• 'Paost . TO' ' •MATERIAL i •, - ESIPLACImorr sualion
IDAquifer Storage and Recovery tiSalinity Haitief • - • .
3 R. 14 II, Sand . ' 2 • •
• . ' . ElAgtilfeiTest ' . -• 1:15101rtnWritce tiraiiiiiF• . . . - , . •
ft, . • • •
ClExperimental Technology . ' it/Subsidence Control . ... . ..
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• .•Vt.',DRILUNGLOG(attach addltiotialsheeCT If nocessarvl " •
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ElOamitennal'Closed Loop) • "OTracer. - '- : , FROM = iru / DESCRIPTION(coloie.hardaves:vantek I3 reir,ritiq!‘ite.ck.l. . .
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EIGeollkenual(Ileatingtobling Return) •1:10ilter(etplaitt under#21 Rettimks) ° • .•.fr• •14 ft.. possible fill . .
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• : 4.Date Well(s)Compleied:-4-3-24 .welt nigmra-2 • - . . _ • . . - - .- . ,
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5a.Wdl Location: , • • ..ft. '.. ft,. . • „
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Greenville Utilities Conmtiasion . - . • • ft. ft ' •/,.L:."./,..,'11.:".7.i" il i:-...,-L.. ' • •
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. FactlitylOrtnerifiutte ' . - . Facility 11:1#(if applkmble) -. ' . - - "" • ft
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240 Aqua Lane, Greenville, NC, 27834 . . 14 • - IL. ' MAY 1 202.4 .
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. . . . . . Pkisinal Addings.City.and Zip ,,21.:iiinfaRics -.
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. .Bentonite seal from 2-3' -
Vitt , . • • . •. • -
. . . • • - DWC:L:7130C • .
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• Cony . . ' , • Parcel IdeinificalIon No.(PIN) - . ' -
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- • 5h.X.atinideaMULOngitnde in itegreesiminuiCsiseetindsar decitnal detreci: . 22.Certifitatiott: .. . . . " .
If 6•01 field,mit:tat/lank is sarneleim . • . • ' - .
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35.607731 N- 77.305984 W .....44q4.2d, . 4,11,2024
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. . . . " Signs. .of ce,fled Well Counactef ' " : ' &la- - • • •-. • .."
. • 6.Islam)the well(S):.XIPermanent .or OTemporaty .6 aignivg this form.'1 Irercby cerly that•Ihr welifs:i was(14r7,1 eth igruclett Or treFordance- • • • •
- ivith 15A NCAC 02C.0/Poor ISA NCACO2C'.0200 Will Consnetioir Standards and Mica er
Is,this a rppair.to an existing well: ElYes or ElNo • ,•vvirfilftliii nvord has Nenprorid(4 tarho'94/owner.
11(rPis"dr a repair;fill out A-a oirh well coosinrcdoa hrforatafion oral riplahr the norare oldie
repair drukr("1 kernarks•Araiail or cm lorIC bark of MA-burnt, • • . . ' 23.Site:diagram or additional well d'etaits:.
•• • . . You ma .use the ti3Cil of this page.to!'provide additional will site details or i'ell.
. - 8.Number of wells constructed: 1 • • - Constmetiott details, You inay also attack adtlitionalpagis if necessaty.
For lajecilokar non-irarer siippki:it ONLY WM Mt.same construkMon,yoii on • .
. • sukutit'onv-forth: ' SITIllti1FFTAL INSTUCTIONS. :: - " . •
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14 • - . (0.) 2.1a. For All Wells: Submit this faint within.30-dais of completion_of well • .-
9.Total well depth below land surface: . .
For nragriple'ivells itsr all depth if&prat,(c.raraph,,3@20tr awl 26,1170) ' construction to the following: . •.
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10.Static water level below top of casing:N/A • -(ft.) Division of Water Restaffed:,Information Processing Unite' .
• • . if marl:level is'above cos*:ase'+" • •,• • - . . 1617 Mail Service Center,Raleigh,NC 276994617 - •
1 I.Borcholetlianicter:8•257 . . :(in.) ' . 24b.For ljitection Wells ONLY: in addition to sentling•the faint to the address-in -• •
24a above. also.submit a copy of this forth within 39 f days:of completion of well • •
. 12.Well cionstntetion'method:HSA - • • rOtistruition to the following: . . .
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(i.e.auger.rotary,•Onble,direct push.etc.)
' ' •• . Division of Water Resources;Un -dergoutod Injection-Control Program
' FOR WATER SUPPLY WELLS ONLY: •• • - • -- 1636 Mall Service Center,Raleigh,NC 27699.1636 • .
. •24c.*6r Water Supply&Injection IVelf.s.1
14a.Yield(gprn) hfethod of test: _
. Also submit One copy of'this'farm Inithin 30 days olcompletion.of"-
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13b.DisinfetiNtur t3-pe: - • -• Amount: . well constructinn to the county hdalth department of tare Coody.where .
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constaleted. I
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Fons,GW-I . North Carblpia[N.-Tantrism of Emirortnris and Natural Resources-DIvitloo of Water"Rootion - Rivised August 2013
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