GW1--03714_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For'usenet lite ONLY
.
The Form can be used for singe or multiple wells
1.Wdl Conlrartor Information:
II.H:►Ilia LONRS
Scott Hunt, Jr 1.110,I1 10 D¢r'('RI►TION
well('n1<ncN•r Name 25 ft. ft. water zone above rock
ft. ft
4561
NC Well Contractor Cenilkarbn Nunrbcr 15.OUTER CASING(for multi-cared welkl OR LINER tit duos!/
nor TO InVklrTFN THIni:NFSS NATteIAL
SAEDACCO n. n. i..
e4m I6.INNER CASING OR
SO11'9ING rheraldmi --~
Camp' Nam __----. _...�... __.-.-'M!P!1 ,
1N1ri1 , TO DLINtTIR THR'KNFSS .I.II NI.I.
2.Well construction Permit k: 0 rt. 12 R. 2 h. SCH-40 PVC
Lin all.rppbi ably t.ril permit(i.e.("malty S1urr.Variant r.14.Eebat el..I ,
IL n. :•
3.Well Cie(cheek well use): t 7.S('RFFN
Water Supply Well: r_Nt)v n/ i DIAUITEK MDT!WY nu ot O '11%11 Nt tl
LlAgncuhural LIMunicipal/Public 12 rt. 32 N. 2 be O10 SCH-40 PVC
❑Geothermal IHeatingCooling Sappy I I(Residential Water Supply mingle) ft. ft In.
'Industrial/Commercial I(Residential Water Stpph !shared/ IL GROUT
FROM to
.t%Tr Pill. F.MrLU FMFNT MI MOO d ANOI NT
❑/rogation 0 n. 9 ft. Portland Tremie
Non-Water Supply Well: <G h.
BMonitonng ❑Recover
Injection Well: n. h.
°Aquifer Recharge GGmundwaterRcnudiaiion It$AN1AVRL PA lit ipplkahlr) .
❑Aquifer Slorrge and Recovers ❑Salinity Hamer Ingri TO .t s r1 P 1.u. Fs1r1.0 rMFNT NFTIN)n
11 ft. 36 ft. Sand 42
❑Aquifer Test ❑Slonmmatcr Drainage tt. n, JI
❑Expennienial Technology ❑Suhsidcn:c('marl
M.DRILLING LOG(attach additional.firers If arer,sar.
❑Geothertal(Closed Loup! ❑Tracer /ROM To DF..C1211PTION!'sire,harder.,,wiknw.lire.era*-i,tore!
['Geothermal 4Heatini,Cuoliig Returnt DOther(explain under N_1 Remarks) 0 ft. 18 ft tan silt
18 ft. 25 ft. blasted rock
4.Date Well(s)Competed: 5-29-24 w•dI IDNP2-6E 25 h 36 ft rock
5a.Wen Location: ft '
_ s
Toyota IL- ' ► ���• 4 `,y
Facility/Dauer Name Facility 1D$(if applicable) - roe i n. ff
J1. 2024
5938 Julian Airport Rd., Liberty, NC, 27298 n. ft. IfA);I, roe _
Physical Address_Cits.and lip `21.RIM vRk4 '•T um
Randolph
Bentonite seal from 9-:L1' ` rAL`
Comm Prrccl Idernrncauun No 'PIN)
5h.latitude and longitude in degreesiminutcs/scennds or decimal degre•s: 22.certification:
.11 wcl:f)eld.uti I:11 Iona t%•Whir iit
N w Sig, -r5 r 4c. 6/3/2024
r•.Cen 4C. d1 Contactor 11..::
6.b(are)the%rills,: 10Permanent or DTenlporary
Bs signing this form,I hereby certify Mai the urllfst teas!weer)constructed is an'ordarrr
wu*I SA NCAC O2C.0100 or I SA NCAC n2C.0200 Well Constar tk it Standards and that a
7.Ia this a repair to an existing well: ❑Yes or El No cart rd this record has brew provided m the urn owner.
If this is a,i'p ur,fill 4,41 Coons w ell!'silos Arta littOrileall.41 and r rplalw the swore of the
repair under/21 remarks sr.-lioa or an the bark of fhix form. 23.Site diagram or additional si di details:
'You trim use the buck of this page to pm..dc additional well site details or well
8.Number of wells c ostructed: 1 crominietion details. You may also attach additional pages if Iicu ssary.
for malnph infection at norm-outer sapph wells ONLY with row same eoaatracnoa Few<aa
salaam one form. SUBMITTAL INSTUCTIONS
9.Total wdl depth below load ferrate 36 (ft l 24a. For AN Wel*E: Subnit this form within zU days of completion of well
For math*'wits list all depths ifdifireat teraatpfr t02OI)'and 2Es Phi) consiniction to the following
II).Static water Mel below top of easing: 20 (p.) Division of Water Resources,Information Processing l nit.
It t,<ur,lr,el r.114,1,t't a,ta(.1.4' + 1617 Mail Service Center,Raleigh.NV 27699-1617
I.Borehole diameter.10.25"/6" tin . 24b.For Inivrtion Wells ONLY: hi addition to sending the form to the address in
24aabone. also submit a copy of this form within 10 days of completion of well
12.Well coustroction nwefhod: HSA/Air Rotary construction to the fellow ing.
.t c auger.rnaly.cable.direct push.a.
Rhision of Water Resource..Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Scoter.Raleigh.NC 2 1699-1 6 36
13a.►itdd tom Method of test: I4c.For Water Supple S.Injection Welk:
Also submit one copy of this Dunn isithm ill days of conpletion of
1311.Disinfection type: Amount: well constnrctisn to the counts health deportment of the county where
constructed
Fong GW-I North Carolina Deportment of Ens nronunena and Natural Resources-Dn moo of Water Resource Rn teed August 2111