GW1--04167_Well Construction - GW1_20230623

`WELL.CONSTRUCTION RECORD Far tr2entai Use ONLY:
lids form can 1 used far single or multiple wells•
1.Welt.Contractor Information:
I:i.LW1TER ZONES . .- . •
Stefan Smith PRIM 1 To Dt+SCIt1Pru1N
Well Contractor Name R. ft. 1
R. rt.
3576-A
NC Well Contractor Certification Nulrber `IS.OUTER CASING(fiir`iiiuht�ciiscrllictI t OR LiNER'tit-ao'Ikabkl`
FROM ! To DIAMETER TOICRICESS atATERAL
SAEDACCO Inc 44 fL' 1 la
Compaq'Name t6:-INNER CASING'OR-TUBING Imsli en:d et 44 iiip0;' '•
FROST TO DIAMETER TITICKNF.SS MATERIAL '
2.Well Construction Permit le: WIO 600241 _ R. ft, ia.
Lis'all applicable well penults li_c.County.Salve,tria,rce,fr}rera'c4 t'sr_l ft. H, ht.
3.'Wcllilsc(checkwell100 -t7.SCREEN . . . . -
Water Supply WelkFROM• TO DIAMETER , SIOTSIZE TRle.KNI.s 1 NAtrnrar.
t'Jrlgtieulntra[ ClilitinicipaUlltblic R It. tit I
ClGeotitemutl(Heating/Cooling Supply) ®Residential Water Supply(single) R. rt. ln. I
❑ludustrialiConmtereial ©Rcsideatial Water Supply'(shared) t9 GROUT_. .._.
FRlTS1 TO. MATERIAL I EMPLACEMENT METHOD 1 AMOUNT
El irrigation ft. rt.
Non-Water Supply'SVell:' . .
It. ft.
oMonitoring IRecovery • „_
injection Well: ft. ft. i
DAquifcrRechar,e QGroundw;itcrRentediatien °14:SANI);RAVEL'PACK'llydp)dicubttr'-..1--
•PROai Ti) • MATtattat. ' NSIP1Ar:1-AllIVI ML'TIIUII
Elpquifcr-Storagc and Rceovety ❑Salinity Barrier R, rt.
❑Aquifer Test ❑Stvrmvatee 1}rlbinage
h. it.
❑Exp rinicntal Tcihnotoir ElSttbsidcncc Control
:211.DRILLiNGLOG tnitjeh additioniil iherls if Itcee'ssan'1-
❑Geothetnial(ClusedLoop) ❑Tr.icer FRO31 • TO • I DESCRIPTION Dolor.haribieu,itd nn4hroe.irl:ire,dm
❑Geothermal(Heating/Cooling Return) ®C)ther(explain under 1k2I Rernaths) .iL rt. 1 1
• rt.- fL I
d:Date Wet(s)Completed: 5/19/23 Well IN IP-1 - IP-32 (Odd Nteaber )1 IL � ^ti
is Well Location: IL- ft. I"A C L ! �° E�61
Robbin Heights Grocery ft.• ft. JUN 2 3 2023
Factlity.OtcacrNaruc Facility MN(ifappli.able) R. U.
503 E. 7th Ave., Raeford, NC, 28376 ft. - ft, in#t''fe' - Ur1e
Pla sietil Address_City:and Zip ' `2 G REMARKS' . .. .
Hoke DPT injections through drill rods
County Pon;e1 Identificallon No,(PIN)
5b,t iltitude'and Longitude in degtreslrniitutcstseeonds or dceiliull degrees; 22,certification:.
(it u en held.ois 1:n,7ol.a is stdficktd)
N W ?i ke iL-1:49
5/30/2023
Si ilfofCedlVcllContractora Date
6.is(are)the N'Cll(s): .[IPeniiAltent or S➢Teinporuiy ay signing this-farm,1 Inerrhy evrrifv Tract the u•dl(sl t;.es(Hera)c'or_rmicird in accordance.
with 154 NCAC 02C,0100 fir I54 NCAC 02 C.0200 R iell Cl?ltstrilrrio1i Sfangaois told Awl a
7.IN this a repair to all CCistlnt;well: OYes Or END rOgfof rills rrarlrr hiiy film provided ra the snrll rimier,
!f rh('s li a wart.fill rnu krona i ell touit cliar'Hrjortaarkn and 1.;.6piaht nit'1 N1rnre of rhr
re pair raider021 rrmarkr..acrirm ar cvr the bank ire Mils form. 23i Site.diagruni or additional well details:
Yea may use the bad:of this page to'ptovide addiuotrat well site details.or Well
8.Nlnulter of wells constructed: 16 • construction details, You may also attach additional pages if necessary.
For ntaiiiple hrj€erh?n or room-wirer smpp))'1vvllt ONLY'Nth the metric carrstrirwfion,you attar
srr6mirr>rie form. St11111iITTAL INSTUCTIONS
9.Total Welt depth below land surface 31 (ft,) 21a..For AR Welly: Submit this form within 30 days of completion of well
For imailrlplelctelklisrrrlideprhstfdiffi'royte..trioipte-.?n200 titiri.2@MY) constmctionto the following:
1(1.Static water level below tap of easing: (ft,) Mishit'of Water Resources,Information Processing Unit,
ifmlhv reeve/is. hove easing.ire"+" I617.RLail.Sen'ice Center,Raleigh,NC 27699-1617
it.'Borehole diameter:2.25" (in.) Herb.For if kliAtliQII Wells ONLY: hi addition to•sending.t a form to the address in
24a above-also submit a.copy of this Nutt within 30 days of completion of will
12.Well construction method:DPT colutmetiau tothe following)
(Le.anger,(e4a1y,cable;direct push etc:}
Division of Water.Resources,Underggrouttd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Malt Service Center.Raleigh,NC 27699-1636
I3a Yield kip]) of tot: 1'fe.For Water Supply&Injection.Wells:.
Also submit one copy of this farm within 30.Oily sofcoulpletion.of
lib.Disinfection hoe: Amount: well constntclinn to the county health depanurent of the county where
constnictcd.
Faun OW-I IN i li Carolina D eganl¢etu of Enr'iroaakiu and Natumi Resources-Division of Water R.4trc Revised August NO