GW1--04685_Well Construction - GW1_20230721

WELL.CONSTRUCTION RECORD For Internal Use ONLY: - i
This form can Ix used for singlear multipk wells •
1.Well Contractor Information:
=14.WATER ZONES •
Scott Hunt, -Jr FROM TO ' DESCRIPTION
wcllCor4muaorNatm 5 ft. 10 ft, white 'silty sand
4561-A ft. ft.
NC Well CamracrorCcmifx�tionNurduer ,IS.OUTER CASING(formultkasn ncflslOR;LINER{if'a Nek6k)
.FROM TO DTAME.TER THICKNESS MATERIAL
SAEDACCO 0 ft, 6 ft. 2.25" in. N/A Steel
Company Name 16.INNER CASING OR TUBING'4Ranibermat closed-loop).
. FROM TO DIAMETER• ,, THIC1;;,NESS MATERIAL
2.Wcli Construct-con Penait#: ft. ft. in. •
Liu aII applicable Iva(penteits(Le.County.Stare,,lrariahhre.Infe(t?ory or.)
R. ft. ka
3,Weil Use(elt(4:W11 DSc): 17.SCREEN
Water Supply Well: - FROM TO DIAMETER snOTSIZF. Ill ICU NI S MIATERIAI.
°Agricultural CDMpnicipal/Pltb)ic 6 ft. 10 R. 1.25" in .004 N/A Steel
• t]Geotlwa.l(Heating/Cooling Supply) ❑Residential Water Supply(single) IL R' it',
❑IndusiriallConw 18.tcrcial ❑Residential Water Supply(shared) GROUT -
FttOM It; MATERIAL EMPLACEMENT AMMO 1C AMOt1NT
❑fripatian ft. ft.
Non-Water Supply Well; ft.' R.
®Monitoring ❑Recovey ,
Injection Well: ft. ft._ '
°AquiferRccliarge °GroundwaterRcntcdiaiion -;1S SAND1GR VELPACK(ifupplieinCe): .
FROM TO MATtIU U, KMPL ACEMENT METHOD
❑Aquifer Storage and Recovety ❑Salinity Earlier. R. ft.
❑Aquifer Test ❑Stormwaterdriinagc R. ft
❑Experimental Technolo5y °Subsidence Control ,
10.DRILLING LOG(attach additional slrcda-if Damson.'
❑Ceotitential(Closed Loop) ❑Tracer .FROSt TO DESCRIPTION(Mgr.lursInco.to nichDirt.men Ate.dm
❑Geothemial(Heating/Cooling Return) ❑Other(explain under A21 Remarks) 0 fL 5 ft. Silty sand
5 ft. 10 , ft. Silty white sand
4.Date Well(s)Completed: 6-27-23 - 'Well IDPB-4ED
yp�y/ t
•
Su.Well Location: fr. ft.
L.. �.�'L`�
R. ft. JUL 2 1 2023
FacilirylOwperNanie Faculty lDk(ifapplieablc) - -
R, •R.
2767 Renric Rd. , Lumberton, NC, 28358 , R. ft,
Initxo. �i1� i'rncsr ura�Utah
DWQ/BOG
Physical Address.City.and Zip '.21.REMARKS
•Robeson Collected groundwater sample via SP-22
Coauly Parcel ldciilifiemiou No,(PIN)
Sb.Latitude and Longitude in degrees/minutcsiseconds or decimal degrees: 22.Certification:
(Irma fie
ld,not Iaationg is sumicletd)N W c50.dL
• � �-_ 17 . 7/4/2023
SigmturecfCeitified Well Cone .ar ' - Dale
6.Is(are)the w ell(a)t DPetmranent or HlTemporary 4 signing this foam.I hereby terrify thus the wdlfr)wax(KrirJ•caraslnrcred is accordance
with f5A NCAC 02C.0100 or l5A NC:IC 02C.0200 We Constriction Standards and that a
7.Is thisi a repair to an existing clli CIYcti or El No ropy oftills record has teen pmridtdto die iirllmown -
if this is a repair,fill rnu k'c,uw well corurrarctlaa information and espial);the nature of the
repair underi2l remarks irclian or on the aura of this form. 23.Site diagram or additional well details:
- You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction derails. You may also attach additional pages if nei:essaty.
For anulrl plc iirfccrlon'or non-Owe supply wells ONLY with die sane constritetlar,yli,can
submit one form. SI1B1HITTAL INSTUCTIONS
9.Total well depth below land surface 10 - at,) 24a. Far All Wells: Submit this farm within.30 days of completion of well
For multiple wilts list all depths ifdifl'i'renr(erample-3@:Ott'and 2@ alai) con5tnletion to the following;
10.Static water level below tap of easing: 5 ((1,) Division of Water Resources,Information Processing Unit,
If mine level is above casing.use"+" - 1617 Mail Service Center,Raleigh,NC 27699-1617
IL,Borehole diameter:2.25" (in.) 24b.far Injection Welk ONLY: hi addition to sending the form to the address in
24a above,also submit a copy of this form within'30 days-of completion of well
12.Well construction method:DPT construction to the following:
(Lc.auger..rotary,cable.direct cask etc.}
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699.1636
13aa Yield(gym) Method of test: 2de.For Water Stitwly.&-Injections Welts:
Also submit one copy of this fermi within 30 days of completion of
13h.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-t Noah Carolina Nictitate-at of Emimrunmi and Narural Resources-Division of Water Rrxotroas Revised August 10 I3