GW1--04545_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD 1r1i For lncrnal Use ONLY:
This form can be used for singe or multiple eclls VV
I.Well Coutractur Information: `'
1a.WAVER toms
Stefan Smith room TO f nrs1 RuriIo\
WcIl Corariot Namc ft. ft.
ft. (I.
3576A
NC Well Contactor Certification Narubct IS.OUTER CASING(for surMi-cased wells)OR LINFR lit applicable)
l FROM TO mA\'TIEN TIIICI\TY: \I\TF RI\I
S EDAcco 0 n. 5 n. 2 ia. SCH-40 PVC
Compton Name I .INNER CASING OR T1JEING potberralcloned•10op)_ -I PROM TO at\\IFTBR MICA M\ITRI\I
2.Well Construction Permit It: R. ft. is.
list all appli.ah4 urllpen.ots(i r.County.Sine.Variance. etc.) R. ft in.
3.Well Ise(cheek well use): 17.SCRUM
Water Supply Well:
PiOM TO ORAMV.TF.R MAMMY Tttt(Tt5105 MATtal5I.
OAgn.ukntal OMunicipal.Pubhc 5 R. 15 Q. 2 010 SCH-40 PVC
OGeothennal(Heating.CoolingSupply) OResideonal Water Supph'single) ft. ft. Of,.
❑htdostrialCommercial DResidcntnal WaterStpph tsktred) 1 CROir
PROM TO MATERIAL EMPLACEMENT METHOD&AMOU T_
0hvgalron 0 ft. 1 R. Portland Pour
Non-Water Supply Well:
—
ft. ft.
B Monitonnl: ❑Rccp\rn'
illjectiela Well: n. ft.
riAquifcr Recharge OGroundwater Remediation it SANDIGILAVKLPACKOfIIPi . Me)
MROM TO M&TRRIAI, !MINAMIrNT\IPTHOn I
❑Aquifer Storage and Recoven' ❑Salinity.Hamer 3 R. 15 ft. Sand #2
❑Aginfer Tat ❑Stommatcr Drainage ft ft
❑F\lncnmrncil Ice hlRaMs'v ❑Sttbsidercc('aarnl It MPG talb.aMllosal sheets itneceesaral
❑Cicothcnnal(Closed Loop) ❑Tracer PROW TO i IMIISCRWIMINttsbr.►pdurw,naknic4QK.wale Vt.Or.I
DGeothetnul(HeatingCooling Return) DOtler(explain under e21 Rewash) 0 R 15 ft. Silty sand
ti n r..
4.Date Well(s)Completed: 7/9/24 Well 1D*MW-4
R. R ;, 4'
Si.Well Location: ft. 1 ft s�—
Coltrain Property R. 4 J
Fa.rl.h On ncr Nanti Facility.Mt(if applicablel R. ft
n-. lam,-1..
4541 US Hwy 17, Williams ton, NC, 27892 II. n. 11 •r••• 3�•r^:45r�
Plnsical.Address_Cit..and Zip ..__,
21.Rl1ulARl�ti
Martin 2 foot bentonite seal from 1 to 3 feet.
(',lima. P:a.c)Id.nrdrr:ninii No IPIN,
Sh.Latitude and longitude in dcgrvcsiminlatcsiseconds or decimal degrees:
22.('enrificatioa:
(if well kW,one Iab1oa is,adI N) /
35.791379 N 77.059213 w r.*,,?4,4 7/10/2024
S,4tutdsiiof CcWrcd W'cll Connector Uwe
6.Ia(are)the wellls): RPr►manent ur ❑Temlworan N,aigriirtg lkir fonts,l kerrbr certify that the Mrlitsl Mar(wrrel sysnrrracred in ocean/cane
with I SA NCAC 02C.0100 tie 154 NCAC 02C.0200 Weil Co natro.rion Srws6,da and the:a
7.Is Iles a repair to an existiag civil: 0''es or K No tarn of rfii,rr.nod ha,1w,.prnlwbd to the wit earner.
11 this is a'woo,(ill tort bsawn u01.<oulsu.two,nforasuu,i uaut a'phut run narrre of the
repair fool,R21 remarL...,r.som...r.w the hock of this fern!. 23.Site diagram or additional w ell details:
Yea m m use the back of this page to provide additional well site details or well
lt.Number of wells awstru led: 1 cotutnu-[ion details. You may also attach additional pages if necessary.
f or maiupie infer-ram or maw-H. , .40(41 a ell.r l\1 1 ..soh the addle cnnatrartim ant tam
sabmir one pro. SUBMITTAL[NSTUCTIONS
9.Total well depth below land surface: 15 if1.1 21a. For All Wdls: Submit this form within 111 da\s of completion of well
For milriple wrils hat all depth,ifdtfrirrns ir.um+p(r-4e:01)'and.'hi 11MY1 constnlction to the following{-
lit.Static water e\tl below top of casing: 8 (R,) Division of Water Resau roes,Information Processing Unit.
If wtJlrr 14.4,4 it.tl+r•iw.alt.z a.e• . 1617 Mail Service('rater,Raleigh,NC 27699-1617
1.Borehole diameter:8.25" (in.) 21b.For(similes Wejb ONLY: In addition to sending the form to the address in
2aaabove. also submit a copy of this form within 30 days of completion of well
12.Well ceenslruction method:RSA consinnction to the following.
44 C.edger.rain.cable.direct push.etc m
Des ision of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Critter.Raleigh.NC 27699-1636
13a Yield(I gnu Method of test:__ 24e.For M mire Sup11i ti Injection Wells:
Also submit one cops of this form within tin dm s of completion of
13b Di infection type: Amount: well conslmction to the counts hcahh dcpannent of the counts where
coltstnicwd
Fors GW-I Nlonh Carolina D.sannrnl of Ew r/oarn-iu aid Natural Resources-Dnxion of N.ucr Resources Roo is d August 2'01,