GW1--05784_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
The form can be used for singk or Imdtipk cells
1.Wdl Contractor Information:
la.WATER ZONES
Rich Lemire YMISI TO I DIKSC Rill ICON
Well Contractor Nana:
ft. ft.
f
2593A ft. ft.
NC Well Contractor Collimation Nutterj IS.OUTER CASING(for nulls-cased weis1 OR LINER(Y applicable)
nom To l DI,NFTFR THInCilsti NVTTIO%I.
SAEDACCO ft. ft. M.
i
('um sun Nang '-16.INNER CASINO OR Tl.'RING t%ember-mat closed-Wain
;ROM To 111t%N1TI.R fullts'r.s NI%IIIOU
2.Well Construction Permit N: 0 ft. 35 ft. 2 In.
SCR-40 PVC
Lin all applicable well prneitr!Le.Conner.Sane.Variance,Injection er,:) ft ft in.
I.Writ I'n 1ehvel:well use): 17.SCRUM
11ata•rNupph %%ell: ►Rost TO Dls%trtFR stDTsirs tHklOtlNS MAT1tmaL
A:;n.ultul:J LI?vlunicip:l6Atbhc 35 R. 50 h. 2 OIL010 SCR-40 PVC
iGeothemtal IHeafin 'Cooling Supply I'Residential Water St ft' ft. IN.
iz pP tpph'(single)
IR GROUT
I lndustriafCommercial I IResidennal Water Supply(shored)
1EOM TO MATFBfNL FNfH_yCEMH9TMF1RODaAMOUNT
7lmgatmo 0 ft. 31 ft PORTLAND TREMIE
Non-W'atcr Supph Welt: R. ft
—
®Monnonne ❑Rceovcr
Injection Well: ft- ft. p I_❑ nl Aglitter Recharge ❑Ciroundwatcr Rccdiation t9.SAN AVEL PACK ft applNyble)
r*ON , TO M-tFRt%I Rtl(MJL(T-NIENIMI1HHln
❑Aquifer Storage and Rccovcn ❑Salinity Barrier 33 ft. 50 ft. SAND $2
❑Aquifer Tess ❑Stomnsatcr Drainage a ft.
❑Espcnmcntal Tozhnologv ❑tiabstdcn:c Control
211.DRILLING LOG Wiwi aillOi0,eul,—Meet,if oecessar.I
❑Geuthennal(Closed Loop I 0 Tracer t1ROM TO orsciurtIION I,,he,horde,•.,,•dLY,wh in Lir.gra.war.ok I
❑Geothermal(HeatingtC•ooling Returnt ❑Other(explain under N21 Bewails) 0 ft 12 ft. BACRFILL
12 rt. 50 ft. BROWN SILTY SAND
4,Date well(s)Completed: 8-30-2024 Well ID11MW-2
R. ft.
5a.Well Location: A. ft
PORT CITY EXXON R. ft.
Faclin.Owner Name Fac lils MN(if applicable)
388 W. Plaza Dr., MOORESVILLE, NC, 28115 H. p• 1,.."
Plirvied Addiesz Cx,.and Zip It.REMA,ak. EP 2 I.r (024
IREDELL BENTONITE FROM 31' TO 33'.
Commomm 1'.ncc]hknld,c:ainn No INN! Ar,..•-'•at
IJe
sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Id welt 6.•Id.nta 1510ng Ic.,dfwaelnl
N W _.Q/Yhv.-t.• 8/31/2024
Srgrulary of Cem Well Contactor Owe
6.Is(are)the wellls): XlPennanent or ❑Templrary g,,ionic ilia ham,l herein eerie";that the teeth's)our(tame)ermrrrnerrd In ae.ondmur
with 154 NC4C 02C,OI t5 or 154 NCAC 02C.0200 Well Cosnrruca'on Swndor.i,and Awl a
7.Is this a repair to an existing well: OYes or EN* .,rrr of file record ha,hem pr.'14e4(to 1hr„rli owner.
If this 1,a WNW'.(ill Mil tnaow well,orutru,non infhraa:tram and r%plain the swore of rhr
repair under 021 remark,en t am or on the back 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 comntrncted: 1 cotnituctwn details. You may also attach additional pages if necessary.
For maths*;nit,rh,n,a n.n-,,,ate,,upph wells ONLY wah rhr Yoe roost:scriMt ,,,s,no
xa(xrtit rwr farm. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface: 50 (rt.) 24a. For AU Wells: Submit this form within iO days of completion of well
For mrulrrplr aril,lint all depth,rftintrre m'enamor',• 76s200'p,s/28'If*YF construction to the following•
lit.Static water lesel helms top of casing: 45 (!ti Division of Water Resources,Information Processing t nit.
Ifstaler level n abort%xt!,•. 1617 Mail Service('cater.Raleigh,NC 27699-1617
11.Bmrehok diameter:8.25" Oa.) 24b.for Inieedon Wells ONLY: hi addition to sending the fort to the address in
24a abase. also submit a copy of this form within 10 doss of completion of well
12,W cll construction method:AUGERS construction to the following.
n c.auger.rcvar..cable.dircn push cic.I
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Raleigh.NC 27699-1636
Ile,Yield 24e.For Water Supph A Injection Welts:
Wpm) Method of test: Also submit 011e copy of this form n ithin 10 day s of completion of
I3b.Disinfection trpc Atnattet•________ ___- well constnction to the county health department of the county where
eonsmicled
Fonn GW-t Nonh Comtism D pmmnteru of Ern moment n t and Natural Resources-Disa.5n of Water Rootrcm Revised Moat 2013