GW1-2021-03309_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD For lrtmrml Use ONLY:
'[M form sin be osod.rot 5j1%k of mottiyle was
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1.Will G1nit'1letor.Ittforntattorr.
Stefan Smith FROM TO DFselupAx, _
Nktl:Caat>imctorl�ame tf. R,
R. %
3576A
NC well ConftworCe__iticstiouNmrlut 1i3O G1StR A dRArJNP.R- 7t Rcabtc
FROM. TO D1.A.'MFr4R TMCK"M MATENtAL
SARDACCO Inc 0 (i. 7 (L 2- M. SCE-40 PVC
C"WO11 ida�r 9k..I :._ AR'. 713G; .,,:'Le► idPlfrsed 1
FROM TO DIA51MR WHCATT M I MAiIMAL
2.Weft Construction Permit(i:
tau all apptiraur wrH penwo(4r.cmrnro%Sat O,Variamr,Tallsc6fn air) d.
I Well Use(check well osc): d-ck
WaterSupphyWl: FRddOM TO _MA{mrs'r'fiR : r:orSIV, THICKNMS MA�P,n_7 R- 22 tt. 2° inO10 SCli-40 PVC P
Ot"rsOMUMai(Heatft%Cooi og'Str 1y) QRssidsnfial Watel'SUMV(sin O m
OlndustliallConlmertiial ORtsidemtial Water Supply(shared) 98 t3Rt)1F! ?:
TROM I TO MATHRW. r "'LACKMINTMMOD A AM UNM
Oftfigation 0 ft. 3 h. Portland Pour
Non-Water Supply Well 0
Mmonhorin Oltcco�mr '
Injection Well: rt. M
O trifaRccharse cGroundrM.ter ltcmediatian
OAt uft Stomgc and Recovery Malinity l3arricT FA M 1ATRRtA't: F1m_A FYT7Nt. n
5 R. 22 rt. Sand I 2
OAquitef Test O$tomm=r VMiMF
OF_xpcdmcntR17tcchnology i]Subsidcnce Contras 2 .:Dtt#tdAl� ACi a1t�c>taitditiomma trctfl3 ttsa
OGeoihemmal(Closed Loop) OTmeer FROM I TO DTrsCRT. ON(ootr#rerdae"v#,tk ro"k „ n bvi
❑Geod"nal ftadurCooligg Renim) 001ber(aciftnunder#21 Remm s) 0 n. 7 (L; Clayey; silt
7 (L 22 R: Cemented silts
4.Date Wel3(s)Completed: 5/6/2021 WdIID#MW-9
SC%%'ellL)esrthm: R. tt.
Durham Army Reserve Center ft. (1.,
r=ilitylUna>WOMc racilih WOOfapgtimble) R. rr, 1Ut�ie
1228 Carroll St., Durham, NC, 27707, ft. ff.
PfiaicatllddMss Giq.M d Zip 3r'.yCl'141 AIR
05: G "
Durham 2 foot bentonite seal from 3 to 51.
CoaaW Paraxt ldemlflcaiiarm No.(hfN)
Sb.Latitude and Longitude in dcgrceslminntetseconds or decimal ilegrT : 22.Cettirkstinu:
(lt»ett Bald.**tat/ioaa 4tuffickal)
35.987564 N 78.918126 W 5/14/2021
Sign_ of C�'_Wa_C-M-z � Date
6.IS(ire)$me rveli(S}: Pt rttanent or Memporaf}` M'signing ddsfi mr l hemby as h*rhda the x>+16)zas(rrrn•)cawtnrcted in&Wvn "re
with,Bill MCAC 02C',O M or 15A NCAC 02C.O tt'rll Camim rlm Somdarda and Nam a
7.16 this a repair toantilbfingwell: OVes or tt No emserfrhkrrrorrlhasbernprm-Irbilro the mM11Mwwr.
if Ails lira repair,JW Dear 4rmw xyll a owv rtaa lnfamwrion tired replain*aammet of dw
"Wirwedera?1 remarks semi er an-flit bw*of drls.form 23,Site diagram or additional well detalls:
You,may use ibe bad;of this page to;punide additional well site derails or well
O.Numlfer of dells constructed: 1 commetion details. You tnay also attach additional pages if necessm y.
for amddpfr InjeaW or mm-iswwr,saarpiy weth ONLY nidi die same conAwakn,,von non
sabmift ne form. Sp$11t1TTAL INSTUCTIOn
9.Total welt depth below land surface 22 {})) 24a. F''ar Ail Wells: Subndt this farm rtithin 30 dqs:of cotVWon of#0
For;Wfipir malls tisr atl*pg a lfdtffermr lerdnp,F,fv 3 .A0`mud 7Ert 41 construction tion to thc;follOn9ng-
to.Static Hater lmt d below top of castor, ((L) Division of Gloater Resource si Information Ptotewng Unit,
1f xsdler kuri is above evuing,-fats"+" 160 Mail Service Ccatcr.Ratdoh NC 276".1,617
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It.gorcholediameter.8° (In.) 24b.,Egr FFalu ion Welts ONLY, "{Tn addition to sending the form to the address in
24o abm- also submit°a oopg of this form`within 30 days of completion of smith
I2 Well 4MtWtMCrlon method: ESA consltuctle0 to the folloixim. 1
(Le.aver.mtnyt•:table.died push ate.)
Minion of Water-R000rera,jiledergvinnd Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 163E Mail Service Ctnter.Raleigh,NC 2709-1636
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134.Viefd(MM) 1Mcth04 of test Uc.For Watcr SuWX aYclWcgmn'Wells.
Also submit one copy of this 156ndi0thin'10 dit)•sofcompletionof
tab.Disinfection hype: Amount: well constriction to the County be hh dcpn6=9 of the curtly wh=
consimcte-d.
Fnmm G%V-t Nmorlh Cmollna Dq=tmem of Emimumera aW Mimal Rcsomocs-,Dhision ofWakr Re vim Aa PM 2013
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