GW1--02740_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECO J R.CA FortrcrnaiU:e°NLY: 1
Thisfonticmb usdforsingleorniultipkwdlsVI.Nell Contractor Information:
Il':ti:WATI ZONES.•'... . .•.i;,i',:..Stefan Smith A,9'‘
FROM i '10 I ut:_,cRtPIROI
Well Cotrintctot Nance \ ft. I ft. I 1
3576A ft. It,
NC Well ConlractorCenifcetionhunber .•IS OUTER'CAS1NCr(tag:atiine.i iienslORLiNF.R(ifajilfkablel • • • •
FROM I TO I DIAMETER TRICKNESS SMATERIAI.
SAEDACCO 0 It. 15 II. 4 in. SCH-40 PVC
C:onvita•Na a t6 INNEt:'CASINGOR.TIBiNG**Olin:maiilosed-liinp) ;+ . - -
-FROM 1 TO -DIAMETER TTOCKNESS MATERIAL
2.Well Construction Permit R: WR0500150 ft. I rt. , in.
Lin ed.'a,tygiroble welprnrarr(Lc.County.S1atc,l'nriarrrr,I.'y°e8•e..r.r.l -
It. ft, in.
3.Well I3sc(check well use): t7z'SC'RtEN'
Water Supply%Vent: FROM I TO DIAMF:TI;R I storsrm THICKNESS I MATERIAI.
CIA�ricuitltrni FJMunicipaltPublic 5 II. 20 ft. 9 in. .020 SCH 40 PVC
IJGeotliemtat(llealinit.Cooling Supply) OResidential Water Supply(single) rt. ft. in, '' I
OIndustrial'Conlnlenaai OReaidential Water Supply(slklmd) 'FROM TO MATERIAL I EMPLACEMENT NIET1100 sk ASIOLINT
❑hrripalion I 0 ft. 2 ft. Portland 'Pour
Non-Water Supply Well:
ft. i ft. I
❑Monitoring fill Recover).
injection Welt; ft. ft.
❑Aquifer Recharge EIGroundwhlcr Rented Wort M SANDiGRAVEL.PACK0r•rinpliable). _
FROM 110 I Si AT[:Rr.A I. ESI HI.A(:E\tEST\1rrIIO,l
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 25 ft.- Sand • 3
❑Aquifer Test OSlomwater Drainage ft. ft.
❑Eytctinicntal Tcchnolagv ❑Subsidence.Con!r l
20:DRILLING LOG(iitlach sddiliotialshcNi if rececssnri•1 ' .
❑Gr..vflteiriaal(Closed Loop) ❑Trtcer FROM I TO I IFSClttPTION([vbr.Lanlncw•i"iL'nmk t)pa•.ttnin t.ira.cft.i
❑Geotltential tfcatineJCuolitia Return) ❑Oder(explain under 1-21 Remac s) 0 ft. 28 ft. silt trace sand
D. ft.
4.Date Wells)Completed: 2/2/2024 well 1DyRW-1 "-' '--
n. ft. • .'l• •t�,.._.t. . '
5a.Well Location: R i'1�•-..
ft, tl.
Wicker Mart No. 10 n. ft. MAY lj 6 2U24
Faeilily.'OnrierName Facility IDi(ifopptiaablc) ft. ft. '
200 S. Horner Blvd., Sanford, NC, 27330 fl, ft. D't`,i Cl2.O y
Plissica)Address_City.and Zip 2L RRMARks
Lee 12 foot bentonite seal from 2-4'
i
Caunh I creel Wealtftc:Iiioti No,(PIron I
•
511.Latitude and I.nngitlide in degrccslminutesfsecnndsor decimal degrees: 'r2•(-crtiticatiau:
(irerell fiW,OM iatao11:1 ix sidlieiadF
35.478456 N 79.179648 W' �— t�j 2/21/2024
Sigmddo1Cc4 ficd'Sell Cantrinor Date
6.is(are)the well(s): XlPennauent or ❑Temporary fry signing arir fans.,f irerehr eerrifa that ihr n'ellfsi was Tamil cur-rtnrrrrd it;nrunh:nc,'
trio)15.1 iNCAC 02C.0100 or i SA NCtIC(IX 0I00 Well'Cotisi rer iron Standards and rise a
7.Is this a repair to an existing well: Dyes or EMI. ropy or 1101-r,•eon!h os Orin provided to a,.NO;owner,
If mi'a is a ten 0r.fill tstt i01,l'n well coosFPJii tietrj Prforrt thOi and,.glom Ale n:tore of M i.
repair muter 02'1 maiorki rrciirt or on flat hod:of this form. 23.Site diagram Or additional well details:
You nun use the bads of this page to,provide additional well site details or welt
8.Number of wells constructed: 1 corlstnrctiun details. You may also attach additim tat pages if necessary.
'fur itudrlple i.th rr•'t>n Or aott-water sum!)wefts ONLI ii1rh i/ie some cnnsrrlrc(io,r.yea c'ao
Miimircar form. Si IibMI'f'AI,INST(iCTIONS '
9.Total well depth below land surface: 20 (ft.) 24a, Fur all Wells: Submit this loon within 3U days of coutplction of welt
pow uittirlplr tills fist fill tAprltc if diliiYoo fc'.rsro'pfr•3 I'200'af4.1 245'10) eonstmotion to clic following: 1
ill.Static water level below(op of casing',: (ft.) Division of Water Resources,Information Processing Unit.
if ware?kw,1.r trbore c'clslo.are"+" 1617 Mail Service Ccnti r,,Italeigly NC 27699-1617
I I.Borehole diameter,l0.625" (in.) 21b.For Nektion Wells ONLY: Itt'addition to sending the foml to the address in
24aabove. also submit a copy of this folio within 0 dw's of conlpletioti of well
• 12.Well cYttlstntetion method:BSA eonatnietiuti to the fbllowiliee:
(i.e.auger.rotary,cable.direct rush.etc.l i
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent&.Raleigh.NC 276e99-1636
I
i3:a Yield(gpm) Method of test: 24e.For Water Supply&injection Welts:
Also submit one copy of this form w'ilhio 30 days of completion of
iJb.Disinfection type:_ Amount �_ well construction to the county depanmenl of tune county where
constntehed.
Form OW-I tionli Calabria t epctnrt:cnt of Encireiurcnr aed Named Resources-Din ion of Water Retotrce Revised August 2*I3