GW1-2022-02951_Well Construction - GW1_20220301

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can tr owd for sindk or m hilik wAs
1.Well Contractor Information:
I-L WAMt ZONES
Robert Miller FROM TO DFSCRIMON,
1Ve11 Cpa(I dot tarlx rt. q.
i
2675
NC Well ComraclorCenificalion Number 15;Ol1TER CASING(for iiulti cased ns OR LINER H i Ikahk
FROM TO 1H.ADtETF,R• THICKNESS NIATERIAL
SAEDACCO inc 0 ft. 12 ft. 1 2" in. I SCH-40 PVC
!'aiitp:otl"N tore 16;aNNER CASING OR T UBING: eulber►nat tlmedaonli}
FROM I TO I DIA1IM11 I THICKNESS MATERIAL
2.WdI CA)nstractirin Permit#: it. rt. hL
List all rtpplirahir roll pennits(i.e.Caton}':State.t'ariam e.lty"M eta-.)
ft. fl. in.
3.Well lisc(check well asc): 17L:SCREEN
Water Supply Well: FROM I To I DIA+fETrit I SLOTSIrs I Tntf'KWNS I MATFRIAL
OAgricultural Omunicipal;Tlublic 12 It. 27 It. 2" in, .010 SCH-40 PVC
Meothemlal(Heatin,B.tCooling Supply) OResidential\Niter Supph•(single) (I. ft. in
131ndustrial/Conmrcrciii 011esidcntial Water Supph•(strand) MXROU . '
FROM. 170 >IATFRLAL I EAtP1ACCMENT MFIMOD R AMOUNT
Olrri ation 0 ft. 8 ft. Portland/Be to
Non-Water Supply Well:
6?Aonitnring ORecovery
Injection Well: a. ft.
DAguifer,Recharge DCroundnatcr 11cowdiation 19.SANDIGRAVEL PAC""it ►ticriAle
FROM TO NATFRI.AI, FMPIAff NFNT M!tHOU
OAgtiferStoiagc and RccogcQ' DSalinin SaRicr 10 (1. 27 ft. Silica and 20/30
❑AgniferTcst OStomm;rtcr Dminagc ft. rL
0EV- crimcntil Technology OSuhsidancc Control
20.`DRiI.LIt\G I.OG(attach`additional shedslititres►an•1"'
OCrootllemral(Closed Loop) ❑Tracer FROM TO MCRIPtIONkobr.hardtivis, Alnieklr dtivuHt.l
OGeothemlal(HeitinttlCooling Mum) Othlter tel( lain under#21 Remarks) 0 ft. 27 to. Yellow 'fine silty sand
ff. ft.
4.Date Well(s)Completed: 1-28-2022 Weil ID#TWP-2 h. fL l
y
52.Well t ocathm: h, ft. AR
Food Mart #10 ft. to.
Fac7ity,fiD%v.rMrile, Facilii)lDk(jr applicable)
ff. ft. I.► :tee ►Qi;�
1150 Virgilina Rd. Roxboro, NC, 27573 p, ft, •?
Ph)sical Address.City.and Zip 2f REMAti1CS
Person Two feet bentonite seal from 81to 10'
Cppuly Mrcel 1t1-.roi6c nittn N0.(PIN)
5b.Latitude and[A)n9itude in degmcs/minutes/seennds or decimal degrecs: 22.Certification:
(if well field,Orrc lat•`lot>g is sidtiti`rr)
W
1\ 1/29/2022
Date
6.Ls(arc)the well(s): MPennanent or oTem11orary
M"aiming thisfi+rm,I herrhr errtife that the antis)mvj;(mrrr)icvieuueted in cwcvrdantr
with 1 SA,VCAC 03C.010)ar i§rl A'CAC 02C,02pp Nell Cnnstrrarirm srolkWi a and Hurter
7.Is this a repair to an existing well: oVoi or MNo COPY Ofthk anOn'!hie been unsettled 101hr•.041mtnrr,
if this is a teimir,fill evil kar;um hell ers+tst»aaioa htfornwrion and c.cplain fir mature of the
wteair i mler421 remarks.eee•tion ar nn the hoick of dais form. - 23.Site diagrom'or additional will details:
You may nse live,back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details: Vou`Inav also attach additioitil pabvs if itecessary.
For rnidtiple in(ecdon to nrxrarrttrr tupph a+ells ON/A salth the some emrsrrurrion,>na e«n
txehnrite�nrj.,rm. SUB11i1TFAL.Ih'ST tiTION�
9.Total well depth'below land slttlaec: 27 (fl) 24a. For all Wells: Subuil this.fond within 311 days of Coinpletion of well
For mtdriple, :etlr list at/drpdrf jj difti rew(ermmplr• @200'mtd 2P Iffl) constmction to the following:
10.Static water level below top of easing: (n,) division of Water Re§ources,Information Prt ciessing Unit,
if muee level is alove caa(ag,we^+^ 1617 Mail So-vice t:ester;Ralcirh.NC 27690-1617
11.Borehole diameter.8.25 m (in,) 24b.For iDlection Wc11s'ONIA% bl addition to sending dtc font to il►e addrm`in
24a above, also submit a copy of this font within 30 days of completion of%%Vll
12.Nell construction method: 4.25^ HSA construction to the following:
(i.e.auger.rotary.rable,direct push cic.)
Division of Water Resoumcs.'Undergmund Injection Control Priogranl,
FOR WATER SU'PPLV WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 21699-1636
13a Yield(Pure) lctluod of test �-For Water Supph.&'iniccthin Wells:
Also'submit on; cop) of.this form witifin 3(l daysofcompletionof
I3b.UisiafiY7ii)n type: _._ Amount: well constroction to the county health department of the connty where
zonslntctcil.
Po nil GW-I Minh Catofina Departruem of Emimiuncut and Natural Resources Division of Nate!ReSoutes Rcviscd August 2013