GW1--03768_Well Construction - GW1_20230602

WELL.CONS` RUC'fION-RECORD Far ttvcraaltfsc.DNLY:. • '
'This-form can be used for single or multiple wells'
1.Well.Conti:titor Information:
`'U ;.WATERZONES . • - •
Stefan Smith FROM ''ID 1 DESCRIt'TION
Well Crnartclor K<rntc R. ft,
3576A ft: rt. • f
NC Well Cornlacior Certification NumberIS OUTER CASING triteiiiattkised sleds)OR LlNLRtif in-lleablc)+-
FROM TO DIAMETER TnICKNE.SS MATERIAL
(I. rl.• la .
SAEDACCO Inc JJJ • '
ConspaurrlimnC• I6:9NNER.CASING'OR-TUBING:I acrihtrmal'clu ed-kiapl • .. . -
FROM TO DIAMETER TRIMNESS MATERIAL
2.WctI Coostrvetitin Permit-14 ft. ' • ft. 'tl1:
Lid XI applicable will prinks fiat Crnrnry.:Stthc,Variance,frig 'GR etc.))
ft.• ft. tn.
3,.Well:Ii5e(diet!:y)'dl asse): -.17:SCREEN -
'Water Supply Well: _ - FROM '10 DIAMETER sr.OTsin: TnICKNPSS 1 MAIPRIM,
gu(eultutal D24ltinicipiWttblic ft: ft. in,
• ElA
°Geothermal(Heatin rCooli ng•Su) l'} .°Residential Water Supplyft. ft. .in,
!t' U t P} (single)
0lndustrialiConunercial • ©Residential Water.Supply(shared") .'Tt)i GROUT: E . . _. . ..
FROSI Tt?. MATERIAL 1 EMPLICENIENT METHOD&AMOUNT
El Irrigation . . . •ft. fL •
-
Not=1Vnter Supply Well .
6dMoniloring DRecm•ery _ , w If
.Injection Wed; . ft. ft..
OAgniferRcchargc gClionndwaterRcincdi;itiou `-19 SANDidRAVEL'LACK'(ifajrplLshter- _ -
FROM • 10 NI ATERtAI. - 1 •RMPIACEMENT NIf7111OD
DAgilifcr.Stgragc aid Rccovety °Salinity Barrier rt.: (t,
CJ Aquifer Test DStonnisatcr Drainage . . •
ft. (t.
DEgTerimcntal Tcchnatoggy OSnbsidencc Control
'%,It DRILL1'G'LOG7altadh additional sheets if icec"ssar t
OGolhemtal(Closed Loup) DTracer FROM TO nEscruPTto's(L»br,hurtlnemsri4'rnck OW::.rtun site,dt.1
DG.otheitnal(HeatinuCooliug Return) DOiher(explain under#21 Retuades) 0 .tt.. 14 ft, silt with'sand lens
14 It: 30 It. sand, {P'� r �.,q — r .a?l,�y .�
.4:Date Wel1(s).Completed: 5/3/2023 Welt DrtRDC-2 ft ft. y ..1.J Z"'.• =---— .
50.Well Locution: rt. IL 20•[3
J U ti (f
Pearce's Grocery . ft, ft, '
Faciltty.'C wocrNmac - • Facility IDS:(`ifappix:ablc) — i,: '111` le<,i; i1 U
4695 Pearces Rd., Zebulon, NC, 27597 . • . rt. . ft,
Plnsical Addiest.City_and Zip 21:RENlARKs-
• Franklin DPT grab- sample using SP22 sampler at_3 intervals
County - ] accl Id airie iiouNo.(PIN)
5b..Latitude and'l.ongttirde in degrees/rninutts/seconds iir-decirnal dcgfecs:• 22.C'ertitieation:
tit.oat!1kld,oree!MAWS i$•srdfeieIU) '
%
35.916147 N 78.307203 VY - 5/9/2023
Sigi t" ofce.;fi d Welloatnstar'— Dale
6.rs(are)lhe.well(s)t.1:Permanent or SITentporarti' h,ti ilr signing r faiirr,,i hereby eertifv'fhru rlrr,irll(sl way(r,rrdl roegtireteri to;utvonlmiar•
with I51 rVCIC 02C.0Ip or 154.NCiC O2C.,02001Weil Constrr+rftnn Srandanti<fnd rlssra
7.is this a reit:di-to alit isttngwell: 17Ye. or KINte etprof riilr retrial ii,'4Neu provided roohe uiril ruttier,
if thly.di o ret.Tlr,fill(Nit ha+,tidal well nonsnuetlori lrr/orrrritrhni twu7 t'Sp(A)1t flit'rntaue of Mr •
'repair under dt'i-revnari s sixties pr iw she brunt of this forts 23:Site dillgrart or additional well details:
You ma}'_use the back of this page to provide additional well site details:or Well
8.ISutuherof wells constructed- 1 • . consttuctioti details, You'nay ilia-atlachadditiouat pages if necessary.
For aaaltiple rrtjeerion o,-o wI-❑erer ruppiy wells ONLY airli rht.smrreci*rrstr'frrrion,you ma
=knit one form. SUBMITTAL INST LICTIONS
9.Total Welt depth below land stiff:Wei 29 (ft,).•2da. For Ant Wells: Snhntit this fonn within 30 days of comptction'of well
Fornrnitipk iorllsllsr all depths ifdlfiiv<•n'(errrrpk•-d@200'and 2@lOfft construction to the foltotting-.
10.Static water lei'el ltclow top of casing (B,) Dh isitin of Water Reumrces,lnfhrtntttiun Processing Unit,
if toner level ds dtbove ensfnq,etra"-" 1617 M til.Scnlec Center,Raleigh,NC 27699-1617 .
11.Borehole din nctcra 2.25" (in,) 241i For infection Wells ONLY: in addition to-senditigthe form to the address in
24a above_also submit a.copy of this faint within 30-days'of completion of well
12.Well construction method:DPT -construction(o-Else following" '
0.e.auer,rotary,cable direct push.etc.}
Dlvisloit of Water Resources,Underground Injection Control.Program,
- FOR WATER SUPPLY WELLS ONLY 1636 Mall Service Center,Raleigh,NC 27699-1636
13a Yield(kgirm) "Ltctllod of test: 24e.For Water Supply&Injection Welts:
Also submit one copy of this form within 30 dab'sofcontpletion.of
13h.Disinfection type: Amount: well constmction to the county health department oe the county wile=
constructed. I i
I
Form GW-t NonhCrolina Dcpamacnt of Enyiroruo u and Natural Resources-Division of Water R.aLrc Revised ALrgust'11)I
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