GW1--02749_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD "- - i
Far num!Use ONLY; • •
This form can be used for single or multipk wells i . . .
1.Well Contrtetar Ittformation: ,
14:,S1ATERZONES •
Stefan Smith ' . FROM-- TO - DESCRIPTION 1 - '
Well C'or factor Name, - •
R.' It.
3576A ft. cr. I 1 .
NC:1Ve11CardmclorCenifteMMnNudiicr • 15'OUTER CASING(foriuutti-crsedisetlsl'OIt�LINERQfan lleable) .
. . . FROM •TO ' DIAMETER, ' TIIICKN'FSS MATERIAL
SAEDACCO . . ' ' • fL ft.. in.:
•
Company.Namao I6.INNER'CASING OR TUBING_(tealherro l dosed-loop).-'
. . FROM TO --- DIAMETER.. TRICKINESS MATERIAL ,
2.Well-Construction Pcrmtit#: . ' . ". • R. " . ft. - 'lv. " . .
List onappilicrbie Win pennits(r—€ County;Sluh ,V anrr,hfalc4arc:)' -
. .R • ft. In..'
•
3.Will UN(check Well usejr . 17:SCREEN
- Water Supply Welk• - ' ' - . FROM TO MMANIETFR BLOT SIFE TiIICKNESS I MATERIAL' •
,CJAgliCulttual - CIIG1unicipal/Publtc 0 R. 10 ft. 1" in 010 SCH-40 • PVC
. . DGeathennal ingi(tleatCooling Supply) DResidential Watcr-Supply.(single) fa . fL - in. .. .
- • ' ClIudustria1IConuttercial•- ©Residential Watcr'Supply(shared) tecCR)UT- . .
FROM • TO MATERIAL - ENIPIACEMENE METHOD.QASIOINT
• ❑lriillation ' -ft.- 'ft. .
Non-Water Supply Well:, • R.,. • ft:
®Monitoring . , . DRecor'cty • . . . •
Injectlon.Welt: • . . .ft. ft. .
l7AtluifcrRecharge - DGmutidiratcrRcnicdiation• -Iq'SANb1GRAYELIACK'(ifupplieablei"
FROM' ' TO' 'AtATtlRtAl.' - EMPLACEMF_NTNF7fOtl '
fAquifcrStortgc and ttceoi'cty ASalinity Harrier - R. ft.. '
' DAgtriferTcst DSlormrtiatcrDraiiiage' • ;ft. • •ft.
❑EyaGdmcrifil Tcclino(os}' • ' DSnbsiitci a Control- 520:DRILLING'.LOG(attach additional sheets'if oeccsmnl'
DQeothennal(Closed Loop) . • DTraeer- •. - .FROM TO DESCRIPTION(rotor.hurttnerr,boirtmck typo:min site.cle.) .
OGeotbennal(IleatinedCaoliug Return) D011ier(explain under#21 Reuiatis) .a 'ft' .10 ft. Sand , . . . ' . '
- ft. .. ft. .
' 4.Date Wetly)Coniptetctl: 4-17-24 Weu IDttTW-16 ft, • ft. •
'.,
Sa Well Grcatiiln: ;. . •l .is`li _ :�. .
ft tt MAY
f;
• Buckeye •• ' • • -ft. ' . ft. : i . •
MA I0 ft r!U�
? - . . ' . , - . .Facility ID4(if applicable) ' .Factlit t0xyncrNantc
4914.Buffalo Rd., Selma, NC, 27576 ft. Ire3..i-:4 17;I r•: 147 4',:� UK): -
.rt, ft.. . . L''fdl f3Uv
.Pln3iael Addnssr City-and Zip a21.RLI LU1LS
Johnston Temp well for grab sample. .
Coonly Parcel Ideulifin;ilion No,(PIN)
• Sti,,Lilitudcariillongitudeindegrces/minute&Jscerindsordecimaltlegrax: - .22.Ccrticftion: '
(lf sell Bola,out lailloris is sufllcicnt) . ' .
'35.555181. N 78.297675 . ' . - W *a j/ yV ' ' 4/22/2024 '
Sigeut. .ofcc:fled Well Contractor. �, . - Date •. . '
6.Is(are)the well(s):"fPennancnt .or ;ITemporan' ' - • ...,is ri rh ehir fume,,hereby...coo,rhiu shr,utrllQ,(ma(Kerr)cxvtssnrc-red trraerordmirn
. . iwith 1511 NVCAC 02C.0100 or 111 NCr1C 02C.0200 Weil Conitrucn'on Srarrdards and Aaat e
7.Is this a repair to an existing well: DYer or 111No ' .ceps ofrlmw record has Green prnvirled to tie rirlt owner. '
Ifihls'lsarep~iir;fill tau knooyinritcaa lnrcaloainform!!ottmudrrpiaintheMangeofrole -
repair rank,-el ienrarkskrliun fir on the bock of thii•fprnc - . 23.Site.dingramnor additional well details: -
• You may use the back of this page to prosade•addiliotlal well site details or n'ell •
• 8.Nuntbel-of wells consinicted: 1 - •. cousttuetion details. You may also attach-additional pages if necessary •
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'For mnlrlp1,e hnJecilon ar nost-wirer supply wefts OA'LYlrhh the same cmrstructtur,pit eon .
snliurfr'one forth. ••. - SUi1MITTAL INSTCTCTiONS. ;• ; . ' . . •
9.Total well depth below land surface: �0 ((I,) 24a. For Atl Wells: Submit this farm within 30 days.of completion of'.tint
Far tnahipla'welhlisi all trepan ifd ermis(exmionk-3€200'aula@W0) - -. cons(nrctionto the following;
10.Static water level below top of easing:3 • (11_) Diyi'siun of Water Resatirceit:Information Ptuceasing Unit,'
if Irmo?.level is above.mains.:use"+" I617 Mail Sersicc Co-nter,Raleigh NC 27699L1611.
11.Borchotc dm iaeter 2.25" (in.)" 24b.For lnjotion Wells ONLY: in addition to sending the form to the address in
24a above.also,submit a copy of this;fano within 30 days•of.completion of well
- 12.Wclrconsttuction methods DPP consinictitnl to the folios Iiig: C I"
'tie.auger.rosary.cable.direct push etc.}. • I . •
.
Difisloll of Water Resources,Underground Injection'Crnttrolarogram,
FOR WATER SUPPLY WELLS ONLY: • - 1636 Alan Service Ce{to Raleigh,NC 27699.1636 •
13a Yid/1(gpm) Method of test: •24c,'F_or Water Supply&I ieetton Wells:
. •Also submit one copy of this fonnf'within 30.daysof conlpletionof
13h.Disinfection type: . • Amount: ' • well consiniction to the comity health department of thc,courgy.wheie .
constnicted.
. Farm GW-t Noah Carolina tkpannictu of Emwironmeio and Natural Resources—lllvislon of Water Reeottcns • Revised August:NF1i
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