GW1-2022-09155_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD For ltccrtml Use ONLY:
This form can be used for singk or multiple Calls
1.Well Contractor information:
14.WATER ZONIES•' ,
Chris Ruffer FROM TO I DESCRIPTION
1�'c11 CoiNrigor 1aini,
4223-A
NC Well ConincaorCenificat ion Numbcr 1S:OUTP.R'CASiNG(for aiulfI=caiW-vergs OR1<ilY£R .a lkabk
FROM TO DIAMETER, TtitCKNESS AfA7T.RlAI,.
SAEDACCO Inc 0 ft. 9 (1. in in. SCH-40 PVC
<;otigtany N9urC INNER CASING OR.71)BING(eotberiinal clitiedduti'j
FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Constivetion Permit ti: ft. rl. in.
Uo rill applinrhle will pe»rrits(i:r.Co mry.Sfnre,1 arinrrre.11w6cri err)
n,
3.Well 1)se(check well use):
Water Supply Well: FROM TO DIASIEIT:R SLOTS17Z TIII(KNES$ I MATERIAL.
0Agricultural 0municipal1lublic 9 ff. 14 A. 1" IP•` .010 SCH-40 PVC
OGeothcmal(HeafingXooling Supply) UResidemkil\Yager Supph•(single) (I. ft.
0IndustriaUC,onmfcrciA 011csidential Miter Supph•(Shand) �FR MRO� TO NiATF.RUM I F.AfKAFFNI I1T M17MOD R AMOUNT
❑firi ation
Non-Water Supply Well: tti ft.
60Mo storing QRccovcly
injection Well:
0Aquifcr'Rcch,;irgc' 06roundmatcrRenicdiation °•19.SANDiGRAVELPACKtif llkabtti
DAijuifer$iongc and Recovery 05.ilinitt"Ranief YR11M lI, TO fl. -MATF,Rr41, E.MPI.ACIIAWNT MYl'itoll
❑AgtlifcrTcst []Storm%matcrDrtinagc
0E: prr1mcnfal Tochnology OSahsidcricc CatitrDl
10.DRILLING I:OG aitach additional sheets if neccssarr•
OG othemwl(Closed Loop) []Tracer IROM TO DrSCRIPTION k6br,lined"is will!"iCklyfle.• "fi 41c.Mc.
OGeothennal(Hcatiig,lCDolil a Retunli OOdier tcx lain under k1I Renlarlcs) See gho s log ft.
A. ff.
4.Date Wells)Completed: 8/30/22 Wdl tD#Trtw-13
n. rL
50.Well 1.I1cathin: y ,`
HCDOT fl. ft. E
Facility/Owner Nanre Faclhy IOR('if appliaihle) ft. ft.
217 US-701, Four Oaks, KC, 27524
PlnsicalAddress.Cite.and Zip Zf RhMARICS` rt::
Johnston 1" PVC temp well for groundwater grab sample
Canmv Pattel Idenlific.,ilimt No.(PIN)
Sh.Latitude and Longitude in degrecxlminutim(seeondc or decimal dgvives: 22•Certification:
(if well fKld,one hvloq it odl ckirt)
N W _ Chris Rafter 9/9/2022�� H
sigavurr of Centrted Well Conimclar Daic
6.Ls(are)fhc wcll(s): :OPennanenl or ZTemporat
Nt-signing this fann,�1 hereby i'eiliri•.rhrtl!hr u•rl1L&l't+ors(Mr1rl evra>.bncred in lr.'r'drrlCnre•
wish`14,t NCAC 02C.010)sir.l S,1 N61C 02C,0200 Well Coturnwrinit SwWArd wul slurs a
7.Is this a repair ft)an existing well: oyes or ENp trpp of this rrcmYl hits(rvrrt p prrid,•d to 1rM zii 11 snrnvr.
lfrhls it a re)MIr,fill inir knrftin well cnrlsulu-tlnrrhtfinrruriltnt End rcploln rite 11n01re of the
relmir tutdrri021 ternarkv.4vjion or aft the hesrk of rhir f,nn, 23.Site diagi•sta or additional ivell details: .
You Ina);:use the back of this page io provide additional Weil site details or well
8.N-umller of wells constructed: 1 consimetion details. You'inay also attach additional pages if n tiessary.
For snalrlple lnfe e-don or'arr,'1.riare'r suptoy irelfs ONI.t'wilt(Ito some comrrurlloir,voa Actvi
svburirnnr faint, C 1 11111 LTtl 1A'STUCTIQNS
9.Total'well depth below land surfaces 14 (ft.) 24a. For All Wells: Slibtf l"this forfi) within 30 days of Completion of well
For itralilple kellsUst all doubt lfdorrem(example-3@200'and 20 IIVY) constnicfion to the following:
10.Static eater level below top of casing: (ff:) Division of Water Resourcesi Information Processing gnit.,
If itmer level L above rnairrg,inw"+" 1617 Mail Smice Center,Raleigh,-NC 276904617
11.Borehole diameter,2.5^ 00 24b.For In icrtion'Wclls ONLY: Tn addition to sending the fom)to ihe'address in
24aabove. also submil a copy of Utisform tiithio 30 days of completion of well
12.Well construction method: DPT Construction 16 floe following!
(i.e.mipm roan':cable:direct psh etc.)
Division of Water Resources.Underground Injection Control Prngraln.
FOR WATERS[sPPLi'WELLS ONLY:` 1636 Mall Scrs'ice Center.Raleigh,NC 276994636
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13a Yield(upnt) Method of test. 24c.For Water Supilby&iniectilm Wells:
Also submit one copy of this forml!withirt S0 daysofcoinpletionof
13b.Diiiinfixtion ty pe:,___ Amount:_._ %veil consmiciian to flu county health cicpsinment of tiro corinily.wlicie
constmocd.-
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Form G11t-I Worth Camilla D6pannlna of Erwironmcia aid Natural Resources-biveloll of 11'aterRcSotrtet Rcriscd August 2013
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