GW1--06594_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW- ) For Internal Use Only:
I.Well Contractor Information: :
Jimmy Morris 4. �t cf4W7,., :a: .: 04 ': L
FROM TO. 'DESCRWTI.ON i
Well Contractor Name
50 ir. SO ft. : Sand t lour e'rock
4193-A tt ft
b 1 -
C Well Caeihartarr Certification Nu 1.,;,mber ` % fttlT tA,f U(ft r i ltt�'t v'a tls 13R I} TE12,#Fws '1;eatele j?`. 1
East Point ContractingLLO 'FROM TO DIAMETER 'THICKNESS MATERIAL 1
ft. ft. itn. .
Company Name `!
toe 1; I1wR#.s't�T. t"s 4I13,TU131�It�li �'usual elo�d-Iaw)S ��;> ., .
FROM TO 1 DIAMETER! THICKNESS MATERIAL
2.Well Construction Permit#: -.:
List all applicable welt caeastrtictlarr permits(i.e:r tIC County,State.I:crriance.etc..f +2 ft' 50 ft' ( 4.r5 in. SDR 17 PVC
rt ft to i
3.Well Use(check well use):
Water:SDppl.'Well: , FROM. 'CO 3,. DLLMETCR SLOTSILF THICKNESS , MATERIAL_
Agrieu1turai Municipal/Public 50 rt•
t.80 ft. 4 €n. .032 PVC
Geothennal(IEeatingiCooling Supply) Rcsidentia)Water Supply(single) I ft: • ft i to
DIndustrialiCommercial DRe.sidential Water Slimily(shared) lc FG1 CIS ,, s[,,s , „, s r ..ai-* `- - „,,,,4,
-_.— irrieatiotl_—__, . FROM TO. , IvIATFRtAt; EMPLACEMENT METHOD&AMOUNT
!an-Water Supply-Well:eild f j Balt�i!—I-Poured — - —
Monitoring Recovery- ft. ft' ir ____ _.._ t
Injection Well: ft. ram.. ft
Aquifer Recharge 'rrauttdtvalex Remediation t,f.SSA*3D{C ;3 `t=SACKlitlii014/s i ' ..• '
Aquifer Storage and Recovery. ',Se,alinity Barrier FROM TO { MATERtAL . 1 FM PLAE,EMF,Nr MLTHC)L!
Aquifer Test OStormwater Drainage 40 ft.' 85 ft. SP#3 i Treittit
Experimental Technology .0 Subsidence Control ft. ft. 1,
Cievtltennat.(Closed l tiap) Tracer It..AIt€11 I I#3, : r t+Ett 2r sr9dltEiiiiul=shwatal(b 2sxart)
FROM TO i 0ESCRWILONicator.hardness,soil/rock typrt,.rain sire,vtc.t t
......_
Geothermal(Heatin IGotI€ingFteturn} pother(explain
21 Remarks) " 0 ft" 8 ft. Orgarfiejsand
4.Date Well(s)Completed:0�12 12�24 Well ID#- 8 ft' 45 rt: .Clay
5a.Well Location: as ft. 85 ft' ( Sand course rack - .- . :--.
Cameron Adams ft. ft. It' r.a (:, t..,; -ii i...iW t
Facility/Owner Name Facility 1Db(if applicable) ft. ft. t►(l,/ 1 y- �rt
1015 Indian Islarid Rd, Aurora NC 27806- ft. ft. i t��,V U
ft ft lr r • ; �,z•
Physical Address,City,anti Zip
Beaufort County w21 1 ICk3 . .� .", r x sx
• County Parcel Identification No.(PIN) -....— �'
•
5b.Latitude and longitude.in degreesiminutesfseconds or decimal degrees: I " "
{tr well field,one latilong is sufticien0 22.Certification:
35.326751 -76 656574 w: e t 10/11/2024
Iature of Certifi. Wet►Contractor Data
6.fs(are)the welt(s) Permanent or _Temporary , _ ,_
J -By signing this forin,I hereby coil i)i that the wells)was(xet'eV constructed in accordance
--
7.Is this a repair to an existing well: Dyes or No with ISAi NC AC 02C 0100 or IS t NCAC.02C,.0200 Well Canstrucrian,Standards and that CI
If this is a repair,filtnut known well wain—action information and.expiai,t me nature of al, cops'of this record has been provided Its the eeelt owner.
repair under fit!reninrks section aeon the back of this firm. 23,Site diagram or additional well details:
You may use the hack of this page to Provide additional welt site details ar wellS.For Gcoproll or Closed-Loop Geothermal Wells�tioving the same conetmiet.an details. You may also aitaeh additional pages if nec
construction,onlyy)1 GW-I is needed. Indicate TOTAL NUMBER of welts
drilled: _ ...•..........— SUBMITTAL INSTRUCTIONS
9 Total well depth below-land surface:80 (ft.) 24a, For All Wells Submit this form within 30 days of completion of well
For multiplewelt lssr all depths ifdfff<erent(example-3 01E and 2(4)1001 �< construction to the.fiilowing: t
10.Stolle water level below top of-casing;1 • - (ft.) Division of Water Resourl ces,Information Processing Unit,
If crater level is-shone ratirsft:use"i-" 1617 Mail Service C enter,Raleigh,NC 27699-1617
IL Borehole diameter:8.75 (in.) Idit.Far Inieetian Welts: In addi iarr to sending the form to the address in 24a
Rotary above,also submit one copy of thil form within 30 days of completion of well
12.Well construction method:• construction to the following:
(i.e,auger,rotary,cable,direct push.etc.)'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: €636 Moil Service Cee!nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Q4+ Method of test:. ilmp Test 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also subunit die copy of this form. within 30 days of
13b.Disinfection type:Sodium Hypo , Amount: 1 Gallon completion of well construction to the county health.departtnent of the county
- where consthueted.
Form OW-I North Carolina Department of Environmental'Quality-Division of Water Resources 1 Revised 2-224016