GW1--04578_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD CD Fof Internal list ONLY:
The font can h;,t..d fm si nOe of in,tb i p A u c f 1,
I.Well Contractor Information;
14.WATER LDIIIIS
Tyler Brown /ROM 10 DIS('RIPI MN___
Well('otarjckM Name ft. n'
4625A , ft, rl,
NC Well Contractor Ceti ifiwtion Number 15,OUTER CASING(far mold-cased wells)OR LINER alksbk)
FROM , TO i m4MrTFR Too s NF\5 Mot Tali!
SAEDACCO 0 m. 42.5 ft. 2 in. SCH 40 PVC
t owgciI �.,aw I(..INNER CASING OR'11 RING 11euth• Inal timed-laip)
F-Hirst , II) Di4.0 fI H nml h,t„ "I II HIO
2.Well('onatruetkn Permit Of: ft, mt nt
Lira all applicable wen pelmet If.County-Stale,le,Wormer.blaroal eh.i
I R. 1 f1. In. f
3.W'ell I've(cheek well owl: .
1'.SCREEN
Water Supply Well:
: Ill D14MWTCR_`HAT3171. tHntk\n4' MAIENIA1.
❑Agrwultura! °Mnnicip9l;Aabhc 42.5ft. 62.5 ft. 2 M. - .010 SCH-40 PVC
°Geothettnal(Heating(Cooling Suppl%I °Residential Water Supph!single) R re rr
OInduslria(IComniercial °Residemwl Water SupphIsh:Ired) 111' "
IQI
CI Irrigation IROM TO MATERIAL-. [ A(YM6VT METHOD&AMOUNT 1
0 Q. 36 ft. Bentonite cetisetie
Noe-Water Supply.Well: - :
❑Monitonni; ❑Recovery
Wet-thin Well: n. IL -4
❑Aquifer Recharge ❑Groundwaicr Reniediaiion 19.SANDI(:ItAS lL PAC_A lif atielkable) i
►ut)t( ill %I.11R111 FMe(.4(1N[NTMrTH00
❑Aquifer Storage aid Recover' ❑Salinity Harrier , 40 R. 66 ft, Gravel pack #2
❑Aquifer Test ❑Stotmeatcr Drainage
R. ft,
❑Eglcnnicntal Technokg` ❑Subsidence('naml -
2a,PR11 11\t,lk)(,tarlach additional sheet+if'iceman I
°Geothermal(Closed Loop ❑Tracer ' IiOTI ! T(1 DFSCwlrTill\n»I.r..Lard mew,w,itvowi nre.lVMM elves rec.'
❑G:odic:mai(Healiug'C'uoling Return) ❑Oder(explain under N21 Rem:ni.si n n.
ft. ft.
4.Date W'rll(s)Completed: 6-24-24 Wdl IDA0W-5D
5a.Well locatNrn: [. " • f '
Hamilton Beach
ri. ft. JUL 3 1 2021
Facility OwNamr Na Facdily fDk(if applicable) ft. ft.
261 Yadkin Rd., Southern Pines, NC, 28387 h''
n. ff. I►;E:,:-;S,i°r,, a.r.yt„f,:,4'SPA
Plotted Addlrss.Cin.and Zip 11.RLMARIVI tkIS'..i SOki
Moore Bentonite seal 36'-40'
(•,,,i,0 Parcel h c,ui ra ate.,No IPINI
4h.Latitude and l.nngtncde in degrtes/minntrcfsr•cnnds nr decimal degrees: 22 Certification:
(if well tkld.one Imilorg is stdl)ekn)
N W' /�� 5��---` 6/24/2024
Sigrum.ofCeeifted Well Contractor Dale
6.Is(are)the wcll(si: XiPertnanent ur ::Temporary
IA signing dal Ions.1 Iirreb,,er(t/v rhos the myths!sous torte,['engasurled an mconia Ice
with 15.4 NCAC 02C.ill(5'or 154 NCAC 02C.0200 Well Commit hem Standards and An a
7.Is this a repair to an existing well: D 1 rs or ENO ,saes.e.f rho.re<-ord ha,f„n i„-.„dash to d'r,roll nwHer.
If lhll 11 a'epalrr,fill last known well,OHUI'm how nf.lrm idol and a plan,the native of the
.rlrtr,..,,f,..#1!rr,„'ri.,sr,ihm or on the bark„t'his farm. 23.Site diagram or additional well details:
N ru nest, a sc ilk back of this page to provide additional well site details or well
8.Number of wells u)nstruetrd: 1 colntru.-uon details. You may also awach additional pages if necessary.
fur mainplr njrcnan all NMI-Wafer rapplt wells ONLY wall the same construction toast ton
Admit one farm. SUBMITTAI.INSTUCTJONS
9.Total well depth below lard surface 62.5 (fl.) 24a. Fur AU Well(!: Submit this form within 30 days of completion of well
For m illiple welds list an depth,ifdt)lrrrnr lctamplr•30200'and'as''LW' constmdlan to the following
1U.Static water keel below hip acentric (n,l Division of Water Resources,Information Processing t nit.
lr ,oaf,,4.,r!'a(dw.rr,asarr.OW . 1617 Mail Service('enter,Raleigh,NV 27699-1617
I I.Borehole diameter:6" tie.) 24b.Fur lnkrtioe Weljj ONLY: In addition to sending the form to the address in
24a abo4 e. also submit a copy of this form within '10 dans of completion of well
12.Well nos ruction method: Roto-sonic construction to the following.
u c.auge,.rotas,cable.direct push etc I
Dhision of Water Resources,Underground Injection Control Program.
FOR WATER St-PP1.1'WELLS ONLY: 1636 Mail See-Ice Center.Raleigh-NC'2"699-1636
I3a l itid IL•pml Method of test: 24c.Far W Art Stipp!) X Injection Wells:
Also submit one cap, of this loon within to dins of completion of
13h_DisinfcYNon tape: Amount: well construction to the cousin health depannent of the county where
- constructed
Fonn(.W-t \VlnhCarolwa L)epunni ni of Er,intone,aid Natural Resources- Doatotaof Wales Rao/roes Hosed AlgLet 24)13