GW1--03769_Well Construction - GW1_20230602

-WELL CONSTRUCTION RECORD For[mental Uso ONLY:-. •
'This forth can bc'uscd for.single or multiple wells• '
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1.WeliCatttractoi hefortaation: '
':24:i ATERZONFS - -
Stefan Smith 114UM 11) DESCRIPTION '
%felt Coiatactor Nano: R. ft, j
It. ft:
3576A
NCWellContractorCertificationMother :t5.OUTER CASING(tor' ulllraycificcRslORL1NER'f[Ciriipticahkl
FROM ' 10 _DIAMETER TER TtIIti cFSS 1 MATERIAL.
SAEDACCO Inc f4 IL M.
Conrp;utj Name- ;16,INNER'CASING ORTUBING: enitinimsd elused-loner, _ -
FROM TO DIAMETER • THICKNESS MATERIAL
.2..W4 Constractirin Permit if: ft. ft.
Litt'aril a}plicabfe will paanti s(i_c..Crnmty,:Sur:e,Variance.kjeCi C4 Kr.)
ft.• ft, in .
. 3:Well Ilse(:lace):R'eli Use)) I7 SCREEN .
Water Supply Well:' FROM TO DIAMETER I stOTst7z TniCKNtts 1 MATERIAL
' ElAgneuiltiral OliltiliicipaUPublic. 6 ft. 'ft. Ia.
DGeatlrelmal(leatingiCooling Supply') IhRcsideittial•WatcrSupply(single) fi• It its.
DhidustrhiliConmicrcial DResidential WatcrSupply(shared') , I'ttl:GROUT ..-. .' . _. . _.' _ -
FRONf TO. MATERIAL - i ENIPLACESIENT NIMIOD i:AMOUNT
Dlrrigutian ft. fL-
•Nou-Water Supply Well: ..
NMoni(oring DRccgNrry • ft.. . _ f - _ .
injection Welt: ft, ft.
0Aquifer Recharge GJCrotuidwatcr R.cittcdiaiion -19 SANUiGItAV1:L PACK'tiftygilieabte)'- -.= ----.-- ' .=, T. '
'FROM TCh • MATER(AI. RSMPLACEHI:Nt'ML'Tttnu
❑Anuifcr.Storagc and Recover-1' OSalinityl3amcr ft,- «.-.
D k:pilfer Test DStormwatcr Drainage ft. It..
Dt W.rinrcntal Tc..hnotott pSuhsidcncc Coninal -
n2II.,DRILL11rG'I.OG'1'altucli adi[Niooal She's if neccssan'I
DGeilthentral(Closed Loop)- DTracer - ET{ONI•• TO ' PFSCRIPTION honor.bardovro,xAsx4 h@G:rdn v✓e,tit.1
OG•Z oMllennal(lieatintCooline Return) DOti er(explain under rs21 Rematt s) 0 .ft. 14 fL silt with sand lens yy��
14 R: 30 ft. - silt"._.d�s slaY t....�.'' .
a.Date Well.(s).Cuulirleled: 5/3/2023 We l inpRDC-1
ft fL
'511:Well farcation: .IL fL . J U N Co 2 2025
Pearce's Grocery . . . . I ft, f(, �� .� D r.^^,�1u'F lax
Facility'?OwocrNarec Facility 1I)k(ifappli:abic}• R. fl, '
4695 Pearces.Rd.., Zebulon, NC, 27597 • ft. ft,. . .
Physical Addit:ss_City.',and Zip ,21'.RE11,LtRKS' . .
Franklin •DPT grab sample_using SP22 sampler at 3 intervals
Cow). Parcel ld<nir.eadon No:(PIN)
Sir..Littitude_nil I.ongituile in dct rces/minutcs/seconds Or decimal degrees: .23:Certifientiou: '
(if%%ell td4.ow.Lm1ois iN.solii.;icad)
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35.916147 N 78.307203• NV _ ( XIMIDI - 5/9/2023
Signii'• afCc.liedWellContractor' Dale
,. 6.Is(are)the\\'eIi(rl}t DPemiidltCttt. fir '1Tt:llttion LN . try signing drir faun..1 hereby certify.that the leafs)tsrcr fs,rnl cori inILiei ir;aconlmnce
with/51 NCIC 02e,0100 or LTA NCrtC 172C.tf00 Ai•ll Cagstrmition Srdndates anti All ar
7.Is this a repair to an existing Is'ell: LJVes or KNo .Criprofthis afford i irSberm provided r ilrc sir 11 rimier. '
If iNs:lta repair.pi cot kirouvt well cYNASIRsCrinni hrf.rrn,7 rion and a tprialn the,snare of the .
r,pcir alder021 remarks sinlian or cm the back ofthisfora: .23:Site diugrsin or additiouni Well details: .
You may use the back of this page to pro'.ide'additional well site details,or Well .
S:Number of Wells constructed: 1 construction details. You ivay also-attach additional pages if necessary.
For maple udecrinn or ciwl-oo;t-r supply wells ONLY utlrh rho urine c ;rstruukou,you e'ela •
sdRmit one.form. . ' SIiBMiTTAI,iNSTCTC'TJONS
9.Total Welt depth below hand surface: 29 (ff) 24a. For All W611s1 Submit this font within 30 days of comp[ctiou'of well
Formalripicicirif'listarilricpthsifdlffi•rant(e-emu)7i--3@'=1A0'anal.;e@slilt)') construction to the folloteing:
lti,Static Ns'ater level below top of casing . (ft.) lih biiin of Water Reinurc_rt,Inforniutiun Processing Unit,
If ledier kiwi lr choir:Asian,;,rim"+" 16.17 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter:2.25" (in.) 24b.F.,;ijrfeclign Wet ONLY: in addition to-sending the form to the address in
Zia-above,also submit a.copy of this form within 30'days'of completion of ihtill.
12.Well construction method: DPT construction tD the followine: '
(to.auger,rotary,cable.direct Push_etc.} . .
Divisionof Water Resources,:Undetgrunnd Injection Control.Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Scrvice-Ccntcr,Raleigh,NC 27699-1636
tint Yield(glint) d'IcClrod of test: 24c.For Water Sultrily&Injection Waist
Also subunit one copy of this'forlit Within 30.daysofconipletionof
13b.Disinfection hpet Amount: well constmetion to the'county health department of'the county where
constructed.
Farm GW-1 Nonit Carolina Depanmcnt of Environment and Natural Resources-Division of Water Rmutrcm Revised August 20l .
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