GW1--05409_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he nscd for single or mu)ttpk netts
1.Weil Contractor Information:
II.WATER ZONES
Tyler Brown PRAM to DEKCRI►t ION
Well Contractor Name
ft. ft,
4625-A ft. ft,
NC Well Contractor Certification NumberIS.OUTER CASING(tor rwMi-easel wells)OR LINER ill Nesbit)
racist TO DtiiMITrR THU I\Vs. ylyfHIAL
SAEDACCO 0 ft. 15 n. 2 ea. SCH-40 PVC
['output)Natnic Ie.INNER CASING OR BING isardierelal cieed-larder ,
PROM TO DIA.MCTBR TRICK'CSS MAMMAL
2,Well Conatrnetion Permit Itl: ft. R, ill
Lu oll opplir able wellpetntio fie.County.State,Variance.11 n'tyt irk.) D. ' - -`
3.Weil I',te)check well sae): 17.SC'RIIN
Water Supply Well: PROM T.a TO DtAMIT SI.f1tS177 THIC1iNIBi I MAMMAL
15 ft. 25 ft. 2 it, .010 SCH-40 I PVC
LI Agrwultural OMunicipal.Publtc j
OGeothenrol(Healinp,Cooling Supply) °Residential Water Supply(tangle) n. f1 is 1
❑IndustrialiComnreteial °Residential Water Supply(shined) 1tR�OQT
FROM TO MATERL41. EMPIA[TMENT MEI100 t AMOUNi_,
❑Itngation 0 ft. 11 ft. Portland JTremie
Non-Water Supply Well:
R. R.
®Monitonni; °Reeovcn ,
Injection Well: ft.. ft.
❑Aquifer Recharge °Groundwater Rcnicdiation 19.SANEIGHAVEL PACK(if applicable)
FROM TO SI An: tsl. P.MM.*(E_MF'iTMITROD
°Aquifer Storage and Recovery ❑Salinity Barrier 13 ft. 25 ft. sand #2
°Aquifer Test ❑Stormwatcr Drninage — ,
ft. ft,
❑E.gmcnnlcmal lctihnolsy y °Safmsidcike('otaml 2o,DRILLING LOG(attach additional sheers if aeeeour%1
❑Gent ennal(Closed Loop) ❑Tracer roam j To . nr.SCRtPtntm\Itnt.r,haudn..,.ow^ehpar,lye vim e r.i
❑Geodknnal(Heating/Cooling Return) ❑Other(es-plain under 4121 Rcutad.$) n• n'
ft. ft.
4.Date woks)completed: 08/20/2024‘‘tli itlnMW-01-N -'i
Ni.,,♦`
+
5a.Well Location: rt. ft. •A 1 t,,,,,
GOOD YEAR TIRE CENTER ft, ft. SEP
e 9 2014
Farm �,•. .:,�, �. Factlfl W#(if applicable) L- r L7 —
1405 Jake Alexander Blvd W. , SALISBURY, NC, 28147 ft. ft. c -
Plnsical Address.City.and Zip 21.RIMARES
ROWAN Bentonite seal from 11-13'
fanl I. Puccl Itknldl: 1 It I.No !MI
Sh.Latitude and IAngirude In degreetininu tc.....I i nil.rn-drrimal degrees: 22.Certification:
Illscll field,ones latiotsg is stdliicwlal
N W' ,/ '_ 8/19/2024
Signiori..of� �__—y`Well Contactor Date
6.Ls tare)the wellts): XPermanent or DTrmporary
fr1 signing dm(ant,I hereby eerily that the welbsl 14115 tarry)cwartnn-ted in a andante
with 154 NCAC O2C.0100 or 154 NCAC 02C,0200 Well Crntatnx•tioir Standards and that a
7.Ls this a repair to an existing well: OW! or No ,..v,,.f rio,record hot hrr„lv.uuud.sl rn ib.•,irll,•wrwr.
it Ilri t:.a rrparr,rill-nut tnawa well,("Ater non information 4Ir41 r,pfaun OW or/rare of the
;..;i,,urdrr 021 rr"turA.t.tr,7ion or on the b,ri of this form. 23.Site diagram or additional well dciAils:
You may use the bock of this pangs to proside additional well site details or well
8.Nileherof celia constructed: 1 eonstntctiun details. You may also zittach additional pages if necessary.
furmaniple„t/e,tlmoenon-water uqr/ .wellsO;.I t wait Our tenor construction ,ow fern
s album'ovwbursa. SUB141LTTAI,INSTItCTIONS_
9.Total well depth below land surface: 25 (f1.) 24a. Fur All Wells: Submit this form within 10 days of completion of well
Fur maniple wells list all drpnhr ifdifferent rrtoenpfr-tad? !and,o*A4r1 Constnnction to the following
II.Static water level below Rap of easing; (ft.) Division of Water Resources,Information Processing l nit.
rywwler let el tr minor naming.use"4." 1617 hlail Service Center,Raleigh,!it'27699-1617
II.R.rebole diameter:8.25" (in.) 24b.For injection Wells ONLY: hi addition to sending the form to the address in
2laabose. also submit a cops of this form within ?0 days of completion of well
12.Well construction method:BSA cotlsttuctiml to the following.
;i c super.race's.cask.direct push.etc.)
Dhisinn of Water Resources,I nderkrnund injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
lit.\aid IMMO Method of Mt
24e.For\Later'Sunnis .S.Injection 1\'elh:
- Also submit one copy of this form wilim t0 dasof completion of
13h.Disinfection opus: Amount: well construction to the county- hcahh dcponment of the county where
cor[stnteted
Fonn GW-1 Nolo Carolina De annrtu of Ern Irotulim and Natural Resources-DO:S.100 of Water Resource Rcs Ned August yr 1;