GW1--03767_Well Construction - GW1_20230602

WELL.CONSTRUCIION RECORD Fur hI-nlalUsc.t NLY:. -- -
This form con 1>c used for single ai multiple Ivens
1.Welt-Contrtctoe•Information:
IJ:.WATERZONiS .
Stefan Smith E'RO\1 TO Dr_Sl'RtPtI(1N
Well Cotantctor Name • ft, f6 , 1
ft, ft:
3576A i
NC Well ContmclarCcniftcalionNurrllcr .IS:OUTER CASING(r?-multi-cr d:tie11s1 OR L1NER'ttf ail licabtct•- .
FROM 1 TO , DIAMETER 1111CtiNESS MATERIAL
SAEDACCO Inc ft. H. 1u.
Iai:INNER CASING'OR TL101NG( e,rtberrnal ctaicddoir It
FROM TO ' DIAMETER THICKNESS MATERIAL
2.Well Construction Permit t:: ft, ft. ht•
fir?u11 applicable lie'permits(Le.Count.Shah,Lbrimrce,!]eared ere.)
ft. fl. M.
3,W'clt use(check:well use): 17:SCREEN
Water Supply Well: - roost 110 DIAMETER sr.or Sin, 71IICKNESS 1 MA/FRIAI.
DAgrtc ultural °MtinicipaliPublic ft, rt. in
°Geothermal(Heating/Cooling'Supply�) °Residential Water Supply(single) fL ft. in• I {
©Industrial/Coumtercial ©Residential Water Supply(slt=1rt:d) 'NI GROUT", .- - -.. _. - - I
FR051 TO. ►LtTERIAL 1 EMrLACEMENT NI61110D&.1-V1oUNT
Elirriention ft, ft.
Non.%Vaier Supply Well:
(l�htnnitctring qR tncp ft. ft.
Injection Well: ft. ft. I
GDAquifer Recharge . QCGrotindwater Reim:di:Ilion t9.SANIi C RAVEL•PACK'tir applicanter
•'FROM •10 :tiATERr.41. • • F:IIYIACEArt:VT MET/10R •
DAin iftr.SlOrogc and Recovery °Salinity Harriet- it.• ft.
El Aquifer Test °SIorninutcr Drainage
It, It.
❑Expe[imcnial Tcehnologv' fSnbsidencc Control
20,DRILLUNG'LOG(:itlac{h additional sheets-if ttccecuiry}.
OCr odtenrutl(Closed Limp) °Tracer FRaost 10 ' or;_SCRtrFlThto/tor.hailiumt 0 R'tWsntx,tx,au u.,:,WA -
OGt othemsal(Heatill t Cooling Return} °Other(explain under 421 Remarks) 0 .ft. 14 ft, silt with sand lens
14 ft. 30 ft. sand ,--- -,..,.v C. 'y il
4.Date Well(s)Completed: 5/4/2023 FVell IDa RDC10 --; • ) r, r�r x�,':,..)
• ft. ft. Pt;..-M
511,Well Lttcatlnn: . .rt. ft. t 9 ./C)Z
Jkiti .t
Pearce's Grocery ft. ft., 11 .r
FacilityiOteocrNnntc Facility MN(lIappli..abie) ; 1-Tr7. -5,1,7s•::F3 '�
4695 Pearces Rd., Zebulon, NC, 27597 ft. ft.
l'In si.111 Addr-ss Cit}:.and iip •21.REMARKS.
Franklin -DPI' grab sample using SP22 ,sampler at 3 intervals
County Parcel Identification W .(PIN) - - '--------- -
5h.I.atitudeanil 1.ongitudc in degrees/minutes/seconds nr dccitit:il degrees: 22.Ccrtifleation:
(I n all t-teld,olio totaling ts•:adileku)
35.916147 N• 78.307203 W / �14(d *` 5/9/2023�,
Sigra ofCe. fled Well Conlractar Date �6.Ls(tie)the ssell(s); 0Pl'n11a1tCRI or SlTemltoran' Hp neonrf rlris fuse..,irerc-tr ref-lily Oar rho n•rll(s)war(+lore.'car,-rrycrrd irr-aetonm r
ti ith 144t NGtC OW.4i0.9 rir 15A ArCrtC(12C,1,O0 Mil Conseroct(nn Srarkeards and amid
7.Is this a repair to an ci istin,,;well: °''es or El No {'rytroj riot$rrrdnl brie Non pr»ruied ra ism snrI rosier,
If rhls'i.a r p ilr,fi(l(Or Srro,rti n'dl c om,m(r1laa hrforeuadon mid r-rpraht the ihiwre of the
repair ruder 021 rrrnar,Cr 5k:don or um the bark of this form. 23:Site diagram or additional well details:
Ybu may use tare bad;of this page to provide additional well site details.or Well
R.Numberof Wells constructed: 1 eonsinietion details, You may also attach additional pages if necessary.
Foritrulriple ndecrlon or oral-wirer supply aa'lls ONLY Aril rhn-srnne construe/on,yin eon
..sunn,irone fore.]. SLTBNIITTAL INSTLTCTIONS
9.Total welt depth beton.Land surface: 29 (ft.) 241a. Fur All Wells: Submit this form within 3U days of conrpletion'of well
For t,rahipirkL(1stisti.d1dnpinth(fdifiToir&•.rrmpfe-.?€2139'cua1.:,,is/OD) - constnrctionto the foltoning:
10.Static seater level below top of easing: (ft.) Billsiun of Water Resources,lufermatiun Processing Uirit,
1f lunar kvel Is chore cvs(rt;,irx•'+'• 1617>LIR Service Center,Raleigh,pNC 27699-1617 •
11,Borehole diameter 2.25" (ia,) 24b.For ftitectl.Qf Wells ONL1r: in addition to sending the form to the address iD
2,:a above.also submit a copy of this front within 30'days of completion of well
12.Well construction method:DPT construction to the following.•
(i.e.auger,iotary.cable,direct push.etc-}
Dt_ viyio it of Vazer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mal Service Center,Raleigh,NC 27699-1636
13a,Yield Wpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this fern within 30 days ofcontpletionof
13h.Disinfection type: Amount: well-construction to the county health department of tic cottony where
constnrcted.
Form GAr-1 Noah Carolina E:panmen!of£ovirarutsciu and Natural Resources-Division of Water Runotrc Revised August 2011