GW1--02750_Well Construction - GW1_20240506

. . WELL CONSTRUCTION'RECORD Fri'irteriialtrscONl.Y:.
Mtn fortn can be used.far single or multiple welts• '
1.WellContrtctarInformation: ' . • ,
. . . IJ:.WATERZONES .
Stefan Smith . .' . •• FROM . To ' onsetKIPTUON i
Welt ContradotNarne, . ft ft,. I I - . • .
3• 576A Ft. FL
• NC Well ConwctfirCcnificalioiiNwdacr. ,iiS:OUTER CASING ira"rtitutti-cascdeictls}°R,Li ERR ail iticatilel-,
FROttr •TO DIAMETER'. , Ti11CKNEss• MATERIAL
SAEDACCO ft., - ft.. iti.
Cotup;my.N;inte - .16:INNER CASING OR-TUBING(g►otherroalelosed-loop); '
FROM - 70 s DLAMETER., TRIC[GNES4 MATERIAL
2,Well Constnictfon Permit If: . . - . . R. . ft" ittr.
Lis' al crligrible weilpe.imin,fie.County.£I.'..Variamre.J,eedclt etca' "
3.Wc11.Use(cheelcwell ase): •• . . 1xsCR!EN
• Water Supply Well: . . ittosr.• i-TO DrAMMETER SLOT SIZE T1I1CHNLISS: MA1100;0;
•
l7tlgricultim[al • C1hliinicipaVFtt6lic . . ' O•.- ft. 10 `ft;- 1" in. ; .010 SCA-40 • PVC
• - _ .®Geothennal(lleati rroolifi. ft_ in,
ng! ng Supply). - ©Residet}tia[Water Supply(single)
•
" ©ludustiialiComniercial : - - DResidential Water Supply Cs-ated) . 7n:GROAT
FROM- TO -- STATER/AL •• EMPLACElfENT•MEf11ODSAMOUNT 1
• Ohrigation . 'ft, ft.
Non-Water Supply Well: '
ft. ft.
®Monitoring ..PRccoyery • •
Injection Well: . h. rL • .
•
' DAgllifcrltcchargc l�Gtoundwaier Rentcdialion' 19:SANDIGRAVELPACK(if applieStiteY .
• "PROM - ' T0' - MATIIRL%I '• .RIPI.WCE:MENTMETtton
IJAgnifcr.Stotagc and itccovcty- . ' DSalinity Harrier ft.. • ft.
•
DAgiifcr.Test 13Stornmatcr Drtinage- • ft. ft.
DEspctimcntal T�hnotog' 1751tbsidcilcc Coitinil . •
• •20;DRILLiNG'LOG!attach addhiooal Sheets if ncccssnrn)
DGeotltennal'(Closeci Loop) , - DTracer . .FROM• TO . . DESCRIPTION(color.Imnlnea,wn'nwk 13 Ft:}arsin nva tic.}
DGeodtemtal(Heating/Cooling Return) IOther(eplaiit under 62.1 Reuiaifs) 0 dL 10 ft.• Sand '
ft ft .
4.,DateWell(s)Campleletl:•4-17-24 %VellllDffTW-18
. ft: f4 !' a.
.a.W..1 lareathtn: . .ft. ft ,r�a r. f ,,, .
Buckeye . . . . .ft. rt. U 2UZ
Facilttyoth•ocrNamc. Facility WR(ifapplicable) , - _ f-_ . . _
ft: ft.
4419.Buffalo Rd., Selma, NC, 27576 :� i. In`�i".~ { .Z . •.�r`w::z -✓r:'s; •
Plwsicnl Addn s City.and Zip '- CH'il c-i'''.�i:, -
• . . 2L RFJ)IARK,S'
Johnston • .Temp well for grab_sample. -•
CoUOIy Nivel I ki Iinealion No,(P1t4) i . , •
Sb.L.atifiitie:and Longitude in deg reeslminutcslteco nds or decimal degrees: 22.Cceticcatlon:
. (Ifuellfield,rom•1.•t!.'lotigissufncletio j
35.555181. N 78.297675 �� _ /(/�/11 - 4/22/2024 '
• ' i gigot Ce. icd Well Contractor- I' '.Dale _
6.Is.(are)the well(.):,DPerinauent _or laTemporan' •Hy signing tine faun:1lrerrbt•certify that tor;uell(si was tweryt crrrutnrcred kr areanlcncw ' -' .
•- ;with lM NCAC 02C,0100 of'ISA NCAC fY'C,0200 Well Construction Standards and that a '
' . •7.Is,this ar.pairtoanexisting well; i7Ye.s or El No allyo,riotrreohitiltsli,iew'nnomikilroibe:tmimenrr..
If tics Is a repair:fill tsar knoihii well com-;nretloa brfomu•rlorr and espial the rirrrare of the. -
' repair rtirrkrs21 remarkSetiairor MI the hark efddx form. - 23.Site dink'rate or additional well details:' '
You may use the back Of this page_to ptov'ide additional well site details or Well -
. - 8,Numberof(wells constructed: 1 - • ' eonslruction details: You May also attachaddiliunatpages if ueeessaxy. - - - '
For tnuitilik btJeerinnor aat-»rner supple n'elli ONLY iridi the genie COST struitiowr,you ntn t u.
rubmit'onc form. SUBNIITTA1,TNSTIIICTIONS. i . .
9.Tot-it well dcpili below land surface; 10 (ff.) 24a. Fur All Wells; Submit diis•fiat within-SO days of completion,of well • _
. 'For ortillittIcwelfslistalldeprbtifdl, erenl(cxaa le•-3@20fran12@/00) • Construction tothcfoltoSsing; , i, , • '
10.Static water level below top of casing; 3 (f') Division of Water Reioureisi InfOrmationPrucessin};Unit,-
if water level Is above rnsijig.use"+" • - . 1617 Mait Service Center,Raleigh,NC 27699 1617
•• • II.Borehole-diameter:2.25" (in.) 246.For Ttifectiott Wells ONLY; TIt addition to sending the form to the address-in
. .2.4a above.also submit a copy of tiiis funn within 30 days'of.completion of well
12,Well constittction"method:DPT consfrnditn►to the following: ( 1
. (i.c:auger.total}•.cable,direct posh.etc.}' i, i • -
' Division of Water Resources;Underground Injection-Control Program;
FOR WATER SUPPLY WELLS ONLY: - 1636 Alan Service"CaitaL,Raleigh,NC 27699-I636 •
13a Yield(gem) ,Nctirod of test: - 2Sc.-Foi Water Supply:tic Injection Wells: • -
• • Also submit one copy of this form'Within 30 days of completion of
136.Disinfection pe Amount: . : well constmction to the county health department of the connty.wlicre
_ constnicted. . • .
•
Form GW-I - - . Noah Carallna Dcpattreen.of Eneitaiuur i11 alto Natur`l Resources-Dluiiloaof Water Reatree. • -Revised August 2013
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