GW1--02743_Well Construction - GW1_20240506

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. . WELL CONSTRUCTION RECORD Fartr��rnni Ilse ONLY:
This form can b:used for singlcar nudtipk wells , -
1.WellContrietorinformation:
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• 14.WATER ZON ES
., Stefan Smith ': . • FROM' TO ' 'DESCRIPTION !
WonConlmtciorNanie ft. • ft. I
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3576A .ft. ft. A.I' .
NC Well ContraciarCcrilikilioriNuriiict • . ' 15.OUTER CASING fret-Dinh i-case4wills).OR•L11YER(if'ap ticahlcl:
- _ FROM TO DIAM).TER.•' ' TRICKNESS• MATERIAL
SAEDACCO It, It. hi.
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Company Nante. 16.INNER CASING OR TUBING(geothermal closed-loop),'
•FROM To DucitETER. TIIICKNESS MATERIAL . .
2.Well Construction Pc Tuit#: . . . R. ft. is
list all milica(,le well peingts(Le.County,Stare;:Varia,icr.TriA•0'C/1 err,i• . - - ,
-R.. ft, •• ..is'
3.Well Use(eked:nell'use) • 17:SCREEN •
• • Water Supply Well• . ' - : . FROM. TO . •DrAMETER 'SLOT sin: THICKNESS MATERIAL. • .
❑agticulniral ClhlunicipatiPublic , o ft. 10 ft. _1" in : .OSO SCH-90 PVC
®Geothermal(Beating Cooling Supply). C]Resideutial Water Supplyr(s'tn�le) ft', ft, rn . . .
OlndustriaUContnteicial- •' - '©Residential Water So -18;GROUT .. -
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Supply(shared) .FROM ' . TO MATERLAL ' EMPLACEMENT{rHrnODSAMOUNT .
' - ' ❑Irrigation .ft. •ft. .
Non-Water Suppl}'Well: • .
• Monitoring DRecorct3' R, tt:
• Injection:Well: . • - .ft. .tt •
• E lAgnifer'Rcch wge ®Cioutiditiicr Rentediation 19.•SANb1GRAVEL PACK(if nlydic stile)"
'FROM - TO - NATRRRI.• - EMPLACEMENT MitliOf ""
E IAi(nifcr Ston c.a,ld Rccov"ct C1Salinity Harrier,.•• . •• rt.. ft , ,
❑Aquifer Test. LIStormwttcr aratnagc, :fL It
' I:Experiment tl Technology. ❑Sihbsidcncc Control
:20;DRU.LiNG'LOG'(attach:additional-sheds if-accessary)
00er:themiat(Closect Loop j ❑Tricer. FROM To . DEScmPUOx rote.Dominos:wirnickOiw.aran Kite.et.1 '
• " ❑Geotltenual(ReatiriglCooling Retuni) : ❑outer(explain:under 62l Retina's) 0 :ft. .10 iI, sand I .
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4:Date.Welt(s)Completed: 4-17-24 .Wait IDai TW-15 — .
fL f4 i '' _ ,z
. . 54,:VealL0E4tinu: . _ ft ft, J 1 JyL.�r )c I.,,.!iw . .
Buckeye • : ft.' . ft. I. ' .MAY 0
t. �U 24
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. . Faciliy,OisarNante- ' . .Facility 1DM(fappicabll . . in<,:r,,
• .., 2- „.
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4414 Buffalo Rd.; Selma, NC, 27576 ft. it. • .., "`' -ur=t
G'fc(.:a.3Ou
Ph tie.al Address.City.and•Zip• ,.2t:ItuttARK.S ,
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. Johnston. _ - - Temp well, for grab.sample:. ;
County Pye:Id,:rrlifi0,lliUa No,(PIN) - .
•Sb j atitudc aura Lr ngttude in., degr'ccs/minuteslsccandsor decimal degrees:
(ltnilifield,uric eviougls:strfficien1) 22.CcttfieaHon:
' 35.555181 N 78.297675 �V ...�' • 4/22/2024
• • •Si mi;,7ofCe. led WellContrxtor � , ,Dale . '. .
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6.Is(are)the well(s) ❑Permanent. or 'ETemporaty . . •il}signing rhis.jome,I lrerrbi certify that'the n•dl{.tJ writ(were)conrrnrc:rd In asronlanrs .
. • WO FM NC,1C 02C.0i00 or(Sri.NCrtC 02C.0200 Well Ccnrslrrietr'ar Standards and that a
•7.Isr this ampairtoanexistingwdl: DYcr or hi No rtrriyofrhh mar rrfhastQrraprmirkd to';Wswill(eener. '
ifrhls'is a repair;fill ocatAPPiiii will corutrucdan Infarnrrlon and rai lain the rurrare pfrhe •
. repair ruder 021 irmarkssrciioa er cm the hark of tltiir form. • ' 23.Site.diagr'am or additional well details:I • •
•You'may.use the back of this page to;procide:additional well site details or well . •
8.Nuniberof wells constructed: 1 . , . • cotistructiondeiliils. You May also attachadditional pages if necessary. •
' Far iitalrlple lreu)oii or anti wart r t'pp3i welts ONLY ulth the sonic cons.rnMion,pl.!con 1
rahmiraie form.• . - SUBh1ITTAL iNSTCTCTiONS. i
' . 9.Total well depth below land surface: 10 • (p.) 24a..141r All Wells:- Submit this•fomi within 30 days of•ooniptetion of welt
Far marlripla'wellslrsr all depths ifdiferent(exarry,lr-3@20Prind.2@AV) . - • cOnstmetianto the rationing;
• • 10.Static water lend below(op of easing:3 - •((t.) ••. Division of Water Resouiaas,Information Processing Unit, •
• ljnanrh'tel1,tibiae casing:use"+" 1617 Mail Service Center,Raleigh,NC 27699-I617 . '
• 11,Borehnte dianictcrt2.25" '(in.) 21b.For rrifectlon Weal ONLY: iit addition to sending the font:to the address•in •
.24aabove.also submit a copy of tliis'fotl within 30 days'of completion of well '
12.Well construction method:DPT ' consimetiou to the follo:viug:
(Le-auger.relay.,cnbh direct pisf�etc.). 'Division of Water Resources;Underground Injection Control Program, '
FOR WATER SUPPLY WELLS ONLY:-- - . • • -1636 Mug Service Center.Raleigh,NC 27699-1636 .
13a.Yield(gprn) Method of test: 24c.For-Witter Supply&Injccttou Welts: .
' Also submit one copy of this fornrl within 30.days of completion of •
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131r.Diainfccctiun hoe: -• • Amount: wet!constmction to the county health department of the.corm y.whese •
constructed.
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FanriGW-t - - • -North Caroline DcpanmentofEu irmmilmand Neutral Resources-Division of Water Rtentitm • .Revised Argust1013 .