GW1--04680_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For'mental l_t..Obi IA•
This Fenn can be mud for ink or multiple Hells
1.Well Contractor Information:
II.WA12R ZONES
Robert Miller r FMON TO DWSCRIr110V
Well['roam Nand: �• ry•
2675 ft. n,
NC Welt Contractor Certification Nnnthci ; IS,OUTER CASING der aw a+i O aiaased weR LINER tit lkabk
' FROM TO nliNr7FII TNICTOTriS MkITITRI
SAEDACCO 0 ft. 21 n. 2.25" Jr. Steel
Company Name _IL INNER CASING O_R_T_yllING trvibermal ekneri4w,)
►MOM TO DIAMETER 111ICAyl%S NPTEMIAI
2,Well Construction Penult M: ft. ft, in.
tear all applicable writ permits lien.Counts: State,l'ariamr !/l'e[O'dl etr.l — f- - -- ----'
ft. ft. in.
3.Well lire(check well use,: II.SCREEN
Water Supply Well: YMOM TO DIAMETISR stOt sin r 11(101!ts 14AT0161.
LlAgrwultwal OMunicipalrAdfhc 21 ft. 25 ft. 1.25" 1tr• .010 Stainless Steel
❑GeothenrolIHeating,CoolingSupple) OReesidental Water Supply(single) It. ft
Oindustria(Comntercial OResidentsd Water Supply(shred) t�01R
M to MATERIAL EMPLACEMENT METHOD a AMOUNT
❑Ims:otwn h- ft.
Non-Water Supply.Well:
ft, ft.
®Motutonne ❑Rocovcty
Injection Well: fL ft.
❑Aquifer Recharge CIGroundwatcrRemediation 1 .SAND/GRA'ZL PACK IYapgMeaMr)
ritON TO NAtt[Rtil. FNW.aftslr\TNrtnon
❑Aquifer Storage and Rccovcn• ❑Salilaty Harrier R. ft,
C Aquifer Test ❑Sromwsatcr Drainage i
I ft. ft 1
❑Evpcnmental Tcthnolog'. ❑tinhsidcocc Control i
it DRILLING LOG(attach additional shres if accc.+an i
❑Geothenlal(Closed Loops ❑Tracer Mom to 1 DFSCMIPTW'.ie"n.r,►.ra.r..•wawwk OW.wok w,est.i
OGeotheal(Heating.•C'ooling Returns I:Other leyplam under#. n.I Rem:nisi R' rye
m
ftt, ft.
f _.
4.Date Wrlt(%)Cumpltied: 7/22/24 Weil IDIB-3 l y-.,.►... . +/ s-..`.
Sit.Well Location: fL h. • A u u r, 5 2024
US Car and Tool IL ry,
FacilityOoserName Facility UM ft lf� R A.:"(�r� 3'+ ►�Ula
11.-- .1
�f1r a�6(
214 W. Hanover Rd., Graham, NC, 27253n.
Mesta tddress.fits.and Zip fL RLMARIi5
Alamance Grab groundwater sample collected via SP-22
fne1M+ harccl W.:indretion.No I PINT
Sh.Latitude and longitude in tk-greesiminutrslseenndsor decimal dewree= 22,CQtlfica6oD:
of wen field.inw lat.long as sod hcmcnlI
N W 7/26/2024
Signatory of. .-.:r•r:c. •: : !•.!:, ,..4"-...— Dale
6.Is tare)the cell(+1: :7Pennanrnt ur RlTempulrar, By signing deir farm,I hereby certify AAar the waist Eros(sorrel c.vnsfnecred in accordance
with I SA NC4C 02C.0100 or 154 NCAC 02C.0200 Well Comma lion Standards and that a
7.is this is repair to an es:istitg well: Dle» or It No espy nfthir word has been provided to to alell owner.
If this as a repair,fill out krwas,a.eit..n•UN,k tlerdr tnformorma an!r spiral tow Aimee of der
repair a der on remarks militia of evi rise back of this form 23.Site diagram or additional well details:
You may use the back of this page to prokide additional well site details or well
8.Number of web contracted: 1 cotutmsYion details. You may also attach additional pates if necessary.
For nwldpk otleevkan or noel-water agaph welts ONLY rah On saner rnnsewsNetr H
%dd.tnirone fr.nn. SIIBMITTAI.INSTIICTIONS
v.Total well depth Inlet land surface: 25 (ft.) 24a. Fur All Wells: Submit this form within 10 days of completion of well
fur multiple wells lit.i at depths el dajfrre•trt te.rumplr.1sg:'b)•and 2'M iniri construction to the foltowing-
11t.State water level below top of caviar:: at i Division of Water Resources.Information Processing l nit.
If note.!r,rl n..h...r.a sin;.a • . 1617 Mail Service Center,Ralcizh,NC 27699-1617
1 t.Borehole diameter:2.25" (ia.) :lb.fur likr-tion Vieth ONLY: In addition to sending die fonts to the address in
24a above. also submit a copy of this fonts within 30 days of completion of well
12.Well construction method:DPT colutmdiun to the following.
li.e.auger.roan.cable.dircil NO,cr,i
Ph Won of Water Resources,Underground IajecUea Control Program,
FOR W%TF.R SUPPLY WELLS ONLY: 1636 Mail Service Critter.Raleigh,NC 27699-1636
13a \idol(L'Imil Method of tr+I: 11C.For%'.aid Gippls &Injection Wells:
Also subnul ate pups of this form nithnl to days of completion of
13b.Disinfection type: Amount: well constrneutne to the county health department of the county where
constructed
Form GW-t Nonh CAM line Dgacmini nt of Em mimeo'aid Natural Resources-Dnrtioa of Water Resumes Res ascd,tygtfst 2013