GW1--05412_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For!mental Use ONI1•
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This toxin can be used Inc single or multiple hells
1.Well Contractor Information:
114.WAT[R ZONES
Tyler Brown 1 rime TO OONCRI►11ON
Well Conracror Nattic ft, ft.
4625-A rt. 1 h.
NC Well Conductor Certification Number j IS,OUTER CASING(for muNl eaued we1M)OR LINER(W livable)
TIN To 1 DNNYTFN TNKKxrss MATT/OM
SAEDACCO 0 ft• 15 ft. 2 M. SCB-40 PVC
l off 41:10 %.r nt la.INNER CASING OR TUBING(jeoMMrwal down-lung) ,
IROM .to r DIANFTFN r111CA\FS1 SI.l IFR111
2.Well(onstr'aetion Permit#: R. It, m.
Liss all applicable urn permits ti-e.Count .Snot.t'orwe r 1r9ecbat err., --
3.well Um(check well*ND 17.SCREEN - - -- -
_---
WaterSupply Well: : room TO m+NrTFR slsnsIll j TNK1041:ss N\Yratat. ,
LIAgicultural LIMunicipal;Pubhc 15 ft. 25 ft. 2 itsO10 SCH-40 PVC
OGeothermal(Healing.Cooling Supply 1 ('Residential Water Supply(single) 1t' is
DhedustriatiComllteaial I(Residential Water Supply(slimed) le*GROUT
PROM TO - MATERIAL EMPT ACEMENT ME11100 E AMOUNT
❑Imgation 0 ft. 11 h. Portland Tremie
Non-Water Supply.Well:
R. ft.
®1Vtwaitonng ❑Rocoscrr
Injection Well: h. , h.
❑Aquifer Recharge OGroundnatcrRcnicdtaiion It SAND1GBAVEL PACK(II a,pNck)
room 1n 1 NATFR1i1, rNM.AtTAUNT NrTl100
OAquifer Storage and Recover ❑Salinity Barrier 13 ft. 25 (I, I sand 112
❑Aquifer Test ❑Stomnsater Drainage "
n. R.
OExpenmcntal Tozhnologv ❑Strbsndencc Control
A DRIl.IANG LOG(attach additional+bees R iaoaasar,)
OGeothemal(Closed Loup) ❑Tracer roost I To DMSCRtPt l0\Itolor,hur new,iel nnek lIpe pain.ier.di.I
❑Geodiemal(Heating/Cooling Remnti ❑Other(explain under 021 Remarks" j h. h. - -
I ft, ft. • ' f. i / ..
4.Date Well(al Completed: 08/21/2024 Wall IDaI' -01-S h. R `'�L-- :,/j�
5a.Well Location: It. h. `'E P 0 9 10Z4
GOOD YEAR TIRE CENTER h. h. +:T'4• ': r._
Facilns f)u err Nei. Peril*.Mk(if +plr able+ Lam.
R R a- -t+3::.. s
s
1405 Jake Alexander Blvd W. , SALISBURY, NC, 28147 ft. ft.
!'Instal Address.fit .and Tip • 21.arm kilo -
ROWAN Bentonite seal from 11-13'
Comm) I'.n.el I ,n,l....awl,No.MIN
5h.Latitude and Longitude in tk urreN: tinutes/seeonds or decimal degrees: 22.Cer'tificatilra:
III null field one lab long t..Wlacienn
K W E�o5—L�_ - 8/19/2024
Si f Cerified WellConlmco Date
6.H(are)the welltsl: XPermanent or ❑Temporary
Q1 signing/kit Jinn.I hereby certify that the*also nvx(twee)newtrinr red an accordance'
WA 1 SA NCAC 02C.01(1)or 15A NCAC(12C.0100 Well Comers.(kW Sara lack and that a
7.Ia this a repair to an existing well: ❑Yes or E No cupr nlrhir non!has been pr.>rrilyd ro toy urll rn.wt•r.
If Mil IS a repair,fin rare knrn.e we11 ralur/re ohm W f(rrmaA,n,a,nl.•tplaln rile,asset nj rho
repair under)?1 remarks section or.e the bark of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if nelxssary.
For multiple utjecra,n,er er.r,rrr.uppl+wellsONLYnrr11ii,rsaanCCa,sfrartaat V.MIao
submit one forte. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface: 25 (fl.) 24a. For All Wells: Submit this form within 111 days of compkuon of self
For multiply wells hay off drpr!„ifdcJhrrn:ir.cr.nplr-tO';01)'mat 24in i Ir)') consemctlon to the foikosin g
II.Static water lei el Ialuw alp of casing: (ft.) Division of Water Resources,Information Processing t nit.
If nale,lr..•l a abort.•ating.,.• • 1617 Mail Service(•cater,Raleigh,N(-27699-1617
II.Borehole diameter:8.25" (ta.l 24b.for injection Weill ONLY: In addition to sending the loom to the address in
24a abos e. also submit a copy of this form within 10 dins of completion of well
12.Well contraction method:BSA construction to the following
I c.auger.rotas.cable.direct push.etc.I
DIYiaion of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONI 1: 1636 Mail Sett ice(enter,Raleigh.NC 21519463h
t3a Yield(fpml xlcnhud of test:
24e.For Water Supple+ sec Injection Walk:
Also submit one copy of this form within 10 days of completion of
13b.Disinfection type: Amount: well construction to the county hcahh depenme,u of the county where
cons meted
Fenn GW-I North Carolina Department of ET imtuurtu and Natural Resonacs-Division of Water Rearms Revised At;tet lot)