GW1-2023-00364_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD For Imcmd Use ONLY.
This form can be used for single at multiple wcls'
1.Well.Contractor Information:
°14-111ATER20NES
Zach Thompson FROM I DtNCRIMON
V►WIContrdctorName tt. fL
4478A
NCWellCalamciorCcitifbotionNumbir SS:OtftERCeLSfA7G foram(fieise�ereRs10R111YER((fa'"tkabk
j FROM TD D61.1tir:TER THICKNESS I 'MATERTAL
SAEDACdo Inc 0- (L 40 (L 2" >a, SCH-40 PVC
CanVartyNiutc ]GINNER CASING OR- HIND ilermidclascddoo
FROM I TO D ETER.• I THICKNESS MAnWAL
2,Well Constmcdon['=lt
List all apprlirable wd1 penhih Ox.County,Starr,Variaore.Ti1reC0�err..)
3.Well Use(chccictivcliuss): j ITSCRUN
Water Supply Well: i PROM TO PrASTr.TM SMTSIM THJCKNESS MATP.RTAr.
40 ft. 60 R. .2n 11% .010 SCH-40 PVC
mgriciiltu al Pm6icipaUPttb)ic
Meothertual(HeafigjCooling Supply) ®Residemial IVater Supply(single)-
DiildustriaUConartacial Mesiden"Water Supply.(slxiJed) is:GROUT
FROM To. MAMMILL 13MPLAC'ENIOT METHOD&AhIOUNr
❑hTi Rt1011 � - (t. .. R.
Non-Witter Supply Well:
iitlMonitodpg .131tecol-cry ft. ft.
Injection well: R• ft.
CIIAt)HiferRecbargr f�GioundtslicrRcmcdiatian t9:SANDicRAVEL PACK Gr tillcaDBr)-
�" THOM To HATFUM1. I RNIPLACF.NFNT MMHOn
CJAquiter Storage aridRccoccty QiKilinityHartic( 38 R. 60 fr.' Filter Sand #z
fJAqu_kfcr Tcst Mlommatcr Drainage
R. tt:
dZVcrimcatal Tvolmotogy Mubs!46cc 6iilrol,
20:DRILLING LOG(attach additions t.sti TtSs if a esun.
13Geodia ntai(ClosedLoop) OTracer FROM To DESCRiMON Mor.hardncn.wt%1mck d Ate,erat
OGeotitemtal(Hearin Cooliu Retum) 1301her{explain under#21 Remarks) 1 0 ft. 60 (L. PATR/Sand
R. fL 1
4.Detc-Wcll(s)C6mplcled: 11-17-22 WclIIDiPMW-6 ft, tL
, dry
Sa.Well iatcatlori: ft.
i
Vickers Village ft. It.
Facility,UwnprNnx,c Facghy IDN 0fnpplicnbJc) R. ft. L
271 Jack Bennett,Rd. Chapel .Hill, NC,, 27517 ft.- rL ` ;y,t� r . '' n
Pltysical.Ygdi City,and Zip 21.REM1i,IRILS'
Chatham Bent6nite Seal from 36,1-38'
county PWro rdcntiCu:.1tion No,(PIN)
ab.I htitudeand Mugttudein dcgrcvs/minutWsc6nd3ordechiml41 toes: 32 CcrtifiradnR: 'F
(itrieit field,orrc 1,1Ulonyit fufilckrd)
35.81888 A+ -79.07507 W /� ` r rw 12/4/2022
r5igmiurbofccitifJ�dWe�tar,; D=
6.I9(are)the well(sy DPerwanent or. .Memporary By signing 1kh fu m,•f herrby cerr fy Mar the irdl{a)rgmr(were)wormcmd to ur.evrd nce
Weir M NOW 02C,0100 or ISAWAC 02C.,0I00 Well 4ousBnietim Sraryiards and rlxrr a
7.Iz this a repair to an existin;well.- hies or M . copy ethli recoirl hos"pmvir&d rbihi ur)l mrncr,
if this is a repair,fill owl Anduvi well coru'tnrcrtoa brfoiraarlon-d a plabi the mrare of rbtr
relmir mrclerAal remanU srri&n army the bask of fM fdrnr. I 23.Site diagrami or additional well detaffs:
You way use the.back of this page to provide additional well site details or well
S.Numberof wells constructed: 1 coustiuction deiaits: You nmy As&attach additional pages if.uecessary.
Foe realtlple.IOT1la)l orrim-water supplyjg1ts ONLY mirk Mo.sameconstraetlar,Pit cirm I
submitonofore.+. SiJBMi iA1,iNsTijen NS'
9.Totd well depth below land surface: 60 I 24a• For All Wells- Subinit dds,furin-within 30 days.gf compled6ti of well
For mulrlple wells fist allrkprhsIfdiferwit(eample-3@26Waruf2@HV3 conitnlctionto the IbItal♦ing; f
10.Static linter level below tap of casing TO Divi$hm of Water R�ounces,Eifnrmation Frucessing Unit,
If Valet level h irbove Mifig.Use"+" 1617 Afai7 Sent ee}v~entcr,Italcigfy INC27.6994617
l
It.Borchot, diamctcr:6° (in.) 24b.For iniectlon WeRS ONLY: !Lt add"Hion to sending the fonu to the address in
24aabo►'e.also submit a copy of this fonu`vitldn 30'days'of completion of well
12,Wcl[constr actiob awthod: sonic. constmetiou to rite following.
{ic.auger.rotary,cable,dirxt poslL etc
:} Division of Water Resources,Underground Iujecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Abil Serviceb'bler,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: 24c.For Water Supply&lniectiod%Vc11s:
Also submit one copy of this foiul within 30 days of completion of
1311.Disinfcctins type:-. Amount: well consiniction to the county hc.l It6 dcimFiment of the county tivWrc
' cottstluctcd. '
Form M11-1 Noah Camlhu M-parommi of Emironmem and Nanua]Resources—ML.loo of WhIerRe Imes Revised ALe st 2U13
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