GW1--02745_Well Construction - GW1_20240506

•
�VELL CONSTRUCTION RECORD Fur keened Use ONLY; •
This form cart Ic used tin's ta Single or ultipk walls .• i
I.Well Conttactar Information:
. i4LWATitR ZONES
Stefan Smith .. - ' . FROM ' TO Di-SCRIPTiON- I
Wall CoiWell Contractorhaale ' .' ft. . f . . . '
3576A ft.• (t: 1 • • • ' .
• NC Well CaniraetbrCcr1lftc�liori Mabel - tS:Ot1TER CASiNG One muttkisedUerisi'OR=LINER tit np?ie'abte}: -
FROST m DIAMETER TFIItK\E55- MATERIAL•
•
SAEDACCO IL ft 1•n: •
Company.Nana Id,INNER CASING OR TUBING kentbarrrlal closcddoop): a
_ ;FROM .to DIAMETER. THICKNESS - MATERIAL _
. . 2.Well.Construction permit zr: . . .• - - • . .. . . R: • . ft: • In.
. List oll applicable w I permits(i.r.Cnirnty:Stale,.Variarrer,Irtle t Crl rlf:J',
If, R. in .
3.Wcl:Use(shale well use): . • ,l7:SCREEN • .
Water Well: Fnosl. .t TO +•DiASIETF:R SLOT SIZE T/11CH1sIs5. 1 MATERIAL
- CIAgricultual DMutiicipaliftsblic' o R. l0 ft. i° .hi Olo sCH-4i), PVC
DGeothms eai(lieatin�CooliagSupply}-. ClResideathal WalerSupply tsinplo) = ft' rL• in.
' ©lndustiial/Conn icicinl DRcsidcntial Water Suppiy(shated) tac GROUT
FROM - . .TO . . DL\TRRIAL • EMPLACEMENT 1ORTHOD.4ASIOUNT '
CI Intention •. • • • -ft. ''ft, . .
' • • Non-Water Supply Well:: .
BiMonitoring . ' • _DRccosrty- fa'
. -Injecdon%Vetto- . f� .. -
Cl'AgniferRecharge C_lOtoundt{aicrRentcdiatioti ' .L9:SANDIGRAVEL.PACK tit aliitienbte),'', -
' Rost - ' TO' • 1LtTRRIAL . . HIPIA(a:KENT METHOD ' .
OAguifcr.Stotagc and ltccovcty F. 1lSalinity H;iiiicr ,ft.. rL.
17AquiferTcst ❑Sivrn SIItcrihaiitaac
ft., • ft.. • .
I70.gICRrllcnlal Tecimotogy 17Sttbsidcn;d CO10tol '20:DRILLiNG'LOG(attach additional sheet it.necessary) • -
OGeopltemial(Closed Leal)) . lTrdcer . . . . .FROM-. TO DESCRIPTION(Rotor.baninea:urn.nfktytfe.rrstn tire.Net
OGeodteitual(Heatimg'Cooline Return) :'DOilrer(esplaiit under A21 Rethinks) 0 r ft.' 10 . ft.-. Sand •I;- , . .
ft:, ft .
' - 4.Date Well(s)Completed:*4-16-24 .Well IDPTW-10- •
it, ft. .
54.1Vell Location: ft. R,- . •; .FT r •
Buckeye - ft. ft.
�iZ;_ t :"
.Facilit},'OorerNantc Facility IDk(ifapplicablc) R. R.- t
. 4414.Buffalo Rd., Selma, NC, 27576 . '
.R. ft.'
Plry3icalAddicss City.UndZip ' lrrio'i 1),-r.•ye.•.:-,... r..,... .
•
2LiREl.IARK.S' r''ii.„'0 . .
Johnston . . Temp well for grab sample., .
CoaWy ' - Parcel hh:olificalion No,WIN} .
Sb.1-niitudcand Longitude in dcgrcesimmnutcstscconds OrIteellnal degrees: 2w Certification:
• (IfACltticid,oirl atnoroissolliekkit) . . .
' 35:555181 ' N' 78.297675 w• 1' '•
' ' 4/22/2024
.• . Signi(, Dicii. . ..
• d Well Conuactar Dale -
' 6.Is(art)the well(s):..OPersnattent of BITemporary • • -lfy signhig this fone;'1 hereby ertriey alas she u•eil{,sl wrls thrrll conanKITCI is occonlance .
irirh 15ri AVCAC 02C.0100 or-1SA NCAC 02C,0200 Rill Consariettoti Standards and:lrsi a
7.Litinsancpairtoanecistingwelli i7Yes or ElNo olviyof Mir'rrcordliasllr-rnproridekd.rotlaiuvllrunner,
if itIs'Li a repair;fill our lacnin iidl car s;iitcriodh iforrnallon era!replabt'tIia natare oleic ' . •
' :repairthrrt'er 021 iemarks.iratiro or on.1he bail of grit fornr. - - ' .23.Site_diagranfor additional well details:
' You may use the back of this page to.pro%lde additional well site details or:well• " • .
. • 8.Nnmberof wells constricted: 1 - - coustluctlon details. You inay also.attachadditianal pages if tiNessaiy. - • •
For tiwtrlp(r In fecaon or amt-umrer supply urlfi ONLY mltli ihr same colratractlon,you ern I
Sz*iii teriePorn. .- _ _ - SUBMITTAL fNSTUCTIONS. I -
9.Total well depth below land surface: 10 (fc) 2.13. For all Walls:•Subntil this faint:within 30 days of completion of µwell
Far mntraplel vetlrllsr aUdrprbs ifdferrns(eramjrhe—J i2 AT and.2@ liar) - Construction to the fottoesiag:. • ' I' ; • .
. 10.Static water level below tap of easing:•3 - - •(it) Dh'kiun,of Water Resources,Information Processing Unit, : .
• ' if wilier-levelIsabovecadag,tic"+" 1617MailScrsiceCentcr,IRailetgr,VC276991617 •
• 11.Borehole diameter.2.25" . ' •(in.) 24b.For Infection Welts ONLY: in:addition to sending-the form to the address in '
.24aabose. also submit a copy of this form within 30 days of completion_of Well
12.Well construction method:DPT • - coustmetlon to the following:- - •
(Lc:auger.'missy.sable:direct pink,pink,etc.}- - ' j - . -
'Disislau of Water Resources;Underground Injection Control Programs:
FOR WATER SUPPLY WELLS ONLY: - - . - - .1636 Mail Service Cent r«;Raleigh,NC 2,7614.163E -
13a 'Yield(gpu! Method of test: '24c.-Fm"Watcr Supply&Injection Welts:
Also'subtiut one-copy-of this form iYithin 30.day sof completion of
-13b.Disinfection.type: - - Amount: - sschi construction to the county health dicpartment of the county.where -
constnicted.
Form GW-1 North Carolina Depannalu.or Environnkluand Natural Resources-
esoues-Division of WalcrResotrem - Revised Argust2013
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