_Well Construction - GW1_20230315 (45)

WELL CONSTRUCTION RECORD For lutsrnal Use ONLY:
This loon can be mcd for single or multipk wells
➢.Wcli Contractor Information-.
'ta.iNrATER ZONES
Brian Ewing 6310111 TO DFicol Tiox
%'WlCrnrtrrclorName R. ft"
4240-B ft. ft.
NC Mil ComractorCenificationNurbcr IS.OUTER CASiNG(roe:stunt-aasednc[Isi ORLiNER(ff:a' fleabk
F11051 TO PLAMF.Ir" TtnCK 11 ' MATEnrAL
SAEDACCO Inc f4 fL I in,
CauTmLy Name MANNER CASING OR TfIBING 4miltermat closed-loon).z ' -
FnO.rr I To I DME•CER• TnICKINESs MATEIUAL
2,Well Construction Permit#: WI0501112 ft, ft, n�
list ull aliplirable wrli pmWis 0-r.Cmmry.Starr.,Variarrca IrferDC4 eir..)
R. ft. ira
3.Welt Use(Check well use): 17:Sc tt>;EN
Water Supply Welk — - Fnoat HY n TO M.TFR SLOTS Tn1C10M I MATRMAI,
❑Agtfcultutal t MimicipaUPublic ft' i1' in
Micotltenna'rl(EIcatinglCooling Supply) ®Residential Water Supply(single) fL IL
tn.
❑liidustriaUConultcicial ❑Residential Water Supply.(shated) tn:GROtrr
FRom TO HATEREAL EMPIACE.NMT HEMIOD&Ah1OUNT
❑his ntiall ft. fL
Non-Water Supply Well:
CIMQDit0ring aRecovcry ft.
Injection Well: rL ft.
OAqu}ferRcchatge 17Gioupda;ticrRcnicdiation MSANDIGRAVEL PACK(if uirlivabte)''
6'n0\r TO MATHRIA1. R51PJAC MENTHETHOn
OA(jnifcr Storage and Recarcr}� ❑Salinity barrier
❑AquifcrTcst OSlormwatcrMlinaoo R. ft.
OiNperfmcnial Technology ❑Subsidence Control
10iDRILLiNGLOG(ansch sdditionalifiects if Accessary
❑Geother m l(Closed Loop) ❑Tracer FROM TO 11MCRIMON(ivbr.hardncn willnrtk type,grOti sir t(t m
OGeolhennal(fiealiiiglCuollne Retunr} ®Outer(explain under 421 Retuaft) h' ft.
ft. ft.
4.Date Well(s)Cdnrpletcd: 2-23-23 `ellID#IP-35-44
Sd,Well Lllcirthln: fL ft. u -
9 -
Former Grocery Boy Jr #5 fL ft. MARrJ
Faclity)OwncrNante FddIity}Dk(ifappli:able) R. ft. -� - r,_:•;
602 W. Chatham St., Cary, NC,, -27511
Physical Address.City.and zip 21.REMARKS
Wake DPT, injection through bentonite packed 6
Cauu1) ParvOldenliCi lf.IonNo.(PIN) boring'
Sb.Latilude and 1.ongitudc in dcgrecs/minuteslseconds or decimal degrees:it 22.CertifiruNgn:
(irr,en few,ory 1;ttrlpug 5rdt7ekrrq
N W Rr''a11 win 3f2,2023
5i;mtun:of Ccrtilicd Well Contractor Daic
6.Is(MI)the-tit'eIIQs): rVermatteut or ETculporary 1h•aigning Ah form,1 hereby certify that Me ngBfs•/%vs fnvnl constrockd fit t romance
with ISA iMIC 02C,01011 or 15+t NCAC 02C,OIOD Hell C6irsrr7icrlon Srarp-Yards cord 0 nr J
7.Lti this a repair to an exixtingwtil: Elves or EMP ccppofrhlr rervO has teen pwridi-d mike uyll mriter,
f/rlrfs 1%o repnlr,fill MirAvoirn rreif coiwnrrrlon brforawr:ox and rxpiahr Me narure of nce
relmir amlrr 021 remarks s ohm or cvi Me bark of Airs form. 23.Site dingrant or additional well details:
You ntay use the bac6 of this page to provide additional%veil site details or Weil
S.Nunsberof Tells constructed: 10 consttuction details. You may also allach additional pages if necessary.
For nrulrlple'lajeralon or aon-owrer supply rvells ONLY rrlrh the saime consrriredon,yhn eaa
S:i(TJAff nne'arr.7. SUi3NIUM 1,INSTUCMMS
?.Total well depth below land smrfac n 26.25 ((f,) 24:L Far All Wells: Suhinit (his farm within 10 drys of completion of well
For smihiple hells list agdeprhs lfdi fermi(exrraip(e-MM'pml Mpy) constriction to 111c foltonia':
10.Static water level below top of casing: 12 (ly,) DiviSiun of Watcr Resources,Information Processing Unit,
11 nwrer level Is above cwslng;use"+" 1617 Mail Service Center,IL•Ilcigh,NC 27699-1617
It.Borehole diameter 2.25" (ta) 2�6.l'nr fiofcetton-Wcfly 141 ONLY: addition to sending the form to the address in
24a abose-also submit a copy of this funn within 30 days'of completion of well
12.`►Yelp construction method: DRIVEN conatuction to the following:
(i.e.auger.rotary,cable direct Fasts efc:} Division of Water Resources„Undergr'ound Injection Control Program,
FOR WATER SUPPLY WELLS ONLY' 1636 Mall Service Center,Raleigh,NC 27699•I636
[3a.Yield(gpm) Method of test: 23e.For.Watcr°Streply&Ipjectlnn Wells:
Also submit one copy of this foram within 30 days ofcomplelionof
13h.DisinfeLtion A-pet Amount: w'etl construction to the cormly h6lih department of the county where
constructed,
Font,GW-t Noolt Carolina Depsilment of Enviroruncrn and Natural Resources-Diviilot,of Water Rasoun6 Revised August_Hil3