GW1--03138_Well Construction - GW1_20230505

Rrint Form i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only;
1."" Contractor Information:
Ronald G Ca6r ady 14t NVXI'HR,ZONEb
Well Contractor I ante — �„ r^F FROMro ULSGmPilol\
e ( i r 05 ft. ELL
m*yr�waonai
NC Well C.oiaraetorCearticationNumbce MAY Q 5 2023 15.OUTILK CASING forinulUcrisedwclls URLINER If a'" Ilcnblc
Canvass Brothers,Well Drill(ng, lac nrto�l ro' nhlntErV rnt RIAt
Company Name Vs^'• ^` ' i ft. 2 in. sch40 PVC
WC22-0010160`s""•8 ., lb.,[NNER'C:151NG,U12T1JB(NG cotficraianlclnscd=tan" r...,:, -'
2.Well Construction Pertnit#: FROM .To DIAMETER THICKNESS I MATERiAL
LIsl all applicable,uW(canstructton pernl(ts(I.e.UIC County,State,Variance:etc.) ft. ft. br.
3.Well Use(check well use): ft. tt. In.
Water Supply Well: 17;SGItLLNvti'„?,° r:'; , 1` ' c.r.
F►P ,
y FRON( TO DUAILTER SLOT SiZE THICKNESS MATERIAL
D Agricultural Munici aL•P.ublic :
p 65 ft. 76 ft; 2 1 In. 0.015 ach40;.' pve wrapped
6eotlierntal(I3eatin'g/Cooling Supply) O'Residential Water Supply(single) R.
IndustriaUCotmnerciaf. [3Rcsidcmial Water Supply(shared)
lrri ration FROM TO bIATEUTAL I EMPLACEMENT METHOD&Aatou,N•r 11
Non-Walcr Supply Well:. 0' ft. 251 , ft- hold plug 3/8; bag poured/a bags'
Monitoring Rccos°cry ft. H.
Injection Well:
Aquifer Recharge DGroundw:iter Rernedialion
Aquifer Storage and Recovery: Salinity 13urrier raoal. To' nh1'r'RIAL EmrtAc alh N t+IET not
Aquifer Test. DiStormwater Dninilge 50 ft• 75 H• Val-1/1a 9TV01 pour
( r,xperinicntal Technology OSubsidence Control n. ft.
Geothermal(Closed hoop) DTracer !10:'DR1L'LiNGIOG hitucliaddiilunitlsliccts'ifncccssary`d' t, . ' L "k,
Gcothermal(Heatin,06olin•Rctum). FlOther(cx lain under 421 Remarks) FROM TO DESCRIPTION(color,Itardecss.solVrock type,grain size c(c.).
0 fL 10 ft. top sand
3-30-23`
4.Date Well(s)Completed:. Well iD# 10 ft. 16 ft. ye116W sand((op water)
5a.Well Location: 15 ((' Y0 ft' clay blacW
Donna Steiner 20 ft. 35 ft. Yellow aend(20-30)/white send(Water-30-35)
Facilhy,Owner Namc Facility ID#(if applicable) 35 ft. 46 ft. Clay block;
2421 S..River. Road,Autryville, NC 28318 45 ft. 65 ft. ' biaeksandIclay :
Physical Address.Cily,and Zip 65 ft 751, ft• "Ursa sand gray(water)
Sampson 02095667002 2Is 1iED7ARxs i.ii.
County. Parcel identification No.(PIN)
71
5b:Latliude and longitude in degrees/mintntes/seconds or decitnal degrees:
(ifwell field,one IaVlong is sunicient) 22.CCrHfieatlon:
35,036024 78.645085
N W la-- 3°
6.1,s(arc)the well(s)[RDIPeflllatlent or OTemporary Signature urCcrtillud Well Contractor Dille
Hi,.slgning thislornr,1 hereby,certify.lhhl the u'eh'(a)riws(u'er•e)constructed lit acc'onlanee
rX
7.Is this a.repair to an existing well: Yes or E3No pith 15:4 ArC•l e 0k.0100 or 15d NC1C 02C.0200 Nrc//Cunslrui-fivn Standar(h'and that a
!/'this is a repair•fill out known r,rl/construction btfar•amNon and cxplgln,lhe nalarc o/'the trolry ofthis record has been provided to the bell owner.
repair under N?/remarAw sr rtion or on the bark q/'rhis fnrnt.
23.51te diagram or additional well details:.
8.Fbr Ceoprobc/DPT or Closed-Loop Geothermal Wells having the same. You may use the.back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAI.NUMBfiR of wells construction details. You may also attach additional pages if necessary.,
drilled;'
;>UBMiTTAL TNSTRUCTIONS
9.Total well depth below•land surface: 75 (ft.) 74a. For All }yells: Submit this form within 30 days of completion of we)I
Por multiple r+rlls list all dcplhsY'dii event(itraniple..i WVOVQ'and @ 100), construction to the rollowing;
Ill.StxUc,water level below to of casing:
35'
P ( Division or Water Resources,information.Processing Unit,
IJ'ridlrr tare 11.r(flint a Cllsblg.use"-I" 1617 Dull Service Center,Raleigh,NC 27699-1617
11,Rorolrolc diameter: 4 7/$ (in.) 24b.For Infection Wells: In addition to sending(he form to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion or ivell
12.Well construction method: construction to ilia followings
(i:c.auger,rotary,cable.direct push,etc.);
Division of Water Resources,,Underground Injection Control Program,
COIL WA'f.GR SUPPLY WELLS ONLY:. 1636 Mail Service Center,Raleigh,,NC 27699-1636
13a.Yield(gpni) 1.5 Method of test: air' 24c. For Water Supply&c Inie t a t Its; In addition to sending the form to
storllne 2oa the address(es) above, also subiiit oue copy of this form within 30 days of
13b.Disinfection type: Amount: PPm.- completion of well construction to the county health department of the county
where constructed, I .
Fenn d W-1 North Carolina Deparineut of rinviro mental Quality-Division Pf Watcr Resourcex Revised 1-22-2016