GW1-2022-05496_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD f 1 FortfCcMduscorilti.:
Ms form can be used for single or mWtiple wells'
1.Well ContraLtor Ldormation:
14z;%VATER ZONES
Scott Hunt, Jr FROM TO MCHIPT-10K
WellCorgnctortlarm ft. ft.
4561-A ft' ft.
NC Well CowactarCenifrcntionNumber f5::0[ITf R CASING for�u[il eiseil'vcc(Isi ORLNfif ck'
T 1tFRoh pAaETeR RSu
hrATEPfAL
SAEDACCO Inc 0 ft, 24 fL 2.25" in NA STEEL
C mpwy Nance 16.1NMER CASING OR T➢IBING' "ther'mal closed-loo ,
FROST TO DlMTETER. TIUCKNESS MATERLIL
2.WPM Construction Per alt d: It. ft,
nisi all applimble well permits(cc.County.Stub.,Yoriamcr.1gkdCA elr.,.)
tt. rt.
3.Well Use(c*lc well use).. 17:scREEN
Water Supply Welk PROM TO DfAMr.TFR StATSOI: WitrCXNM I MATMAt.
❑tlgiiculRllD1 MfuaicipallPablic 24 R. 28 R. 1.25" in. .004 NA STEEL
®Geothermal(HeatillglCooling Supply) ®Residential Water Supply(single) It. %
Mhidustrial/Conuncicial ®Rcsidential Water Supply'(shared) Ie GROUT __ =
FROM TO MATERLU. ENIPrACENMNT hrEMOD&AMOUNT
❑H ation h. fL
Non-Wakki'Supply Well:
dmonitoring pRccotir ' fti
Injection WcU: rt
13AquifcrRcchtirge MGioundwaicrRcmcdiatioa 19 SANDIGRAVELPAcf�rlr idtiatnte)
FROM TO atATnRIAL fthrPIA(MMENTMETIHIn
QAquifcr StoTagc and Recoveryl7Salinity Hamer
❑AquMrTest ❑5tounwatcrDrainage ft. ft.
17E+•perimenaI Technology C sl"dcncc Control
2 1DRILLILIG'LOG7attach additional libediif necessan-1
❑Geodienual(Closed Loop) ❑Tracer FROM To DESCRIMON evbr.hardnen sulYnxk type.mWu Omck.r
❑Geotitemral(Malin Caolin Retum) ❑Outer(explain corder. 2l Reuullls) fL fL See Geologist's log
fL fL
4.Date Well(s)Completed: 4/21/22 Weil]D#Al-A15
(L fL
54,Wt ll Iarcatinn: fL fL e
NCDOT Parcel 90 R. FL r, Z022
Fact7dp,Y?wuTcrNanac Facility IDk(ifappM blc)
fL ft. inh
4443 US-311, Randleman, NC, 27317 R. ft. [)%SAi�/t'3�
Plnzical Md.icss City.and Zip 12L RENIAPAS
Randolph Direct push injection through drill-rod
t tiuul}' Pame]IdenUriCllion No.(PIN)
5b,I.atiitude'and"rigitude in degmes/minuteslsccoinds or decimal d14,nees: 22.Certification:
(Itivell field,orre.11f,7o ;is sufficient)
N W; ��'.d(.C. �l _ 5/21/2022
Sign3wmefccitIr W:cltCa" tar Daic
6.Is(are)the well(s): l7Permanent or MTemporary By signing ihir forur.1 Irermhy rerhfy dua the u4l(s)Knr(µrre)comirucred by arean ruice
frith LU NOW 02C,0100 or 1 SA NOW 7rC A200 Well Contra uion S(arklards and fixer e
7.Isthisa repair toanexistingwell: Elves or ®No copy ofUilrrecofrlhesbrevrprnvidrdTokirurllrntaue,
if rhls'Is o repair.fill ever knouw uvell comirucdon hrfon mrlwr mad e.vplahr Me narare of flit
repair wrderg2l reoaarks seriMn or fur the bcwk of flits form. 23.Site diagram or additional well details:
You may use the back of this page to prude additional well site Retails of well
S.Numberof wells constructed. 15 construction details. You may also attach additional pages if necessary.
Formnldple k#eeV4?n or am-surer supply Teells ONLY midi rile somecenstrucflon,you con
suNnit one form. - SUBSIMAL iNCT TCTiONS
9.Total well depth below land surface:. 28 24a. For All. Wells: Submit this form within.10 days of completion of gill
Formnlrlpiewells8sragdepihslfdaervu(exempfe-t@200'arul2@10'y constmctignto the foiloning;
10.Statie Seater level below top of casing (ft.) DiN'I.Yion of Water Resources,Information Processing Unit,
If isume level h above casing:ate"+" 1617 Mail Saviee C�ntcr,R4l6rh,,NC 27699-1617
11.Bordwle diamch:r:2.25" (in) 246.Tar lnj ern Wetly ONLIt: In addition to sending(lie foml to the address in
24aabove.also submit a copy of this fonu within 30 days of completion of well
12.Well construction method:DPT construction to the following--
(Le.auger.rotary,cable,direst posit etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mull Scrl'ice Center,Raleigh,YC 2 7699-1636
13:1.Yield(gpm) Method of test.• 24c.For Water Supply die Injection Wells:
Also stlbnllt One copy of this form within 30 days of cotupletion of
13h.Dilinfextinn kvpa_. _ _ Amount: «'cif constniction to the county h tsealth department of'the coun where
consmrcted.
Form GIP-L Nodh Carolina Depa nmem of Em'uunswni and Natural Resources—Division of RraferRe_KaUnes Revised August 2t)it