GW1--04967_Well Construction - GW1_20230807

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' WELL CONSTRUCTION RECORD For[mental Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
I.i WATER ZONES
Scott Runt, Jr FRO11 TO DFSCRIFirION
Well Con4raCarNanw 11 IL. 15 - ft. silty sandy
4561-A ft. ft.
NC Well Contractor Certification Niurbcr 'IS.OUTER CASING tformahi-ea"sect o"etlsl•OR LINER fIf-an lieahk)
FROM TO DIAMETER THiCKNESS MATERIAL
SABDACCO f4 rt. ' I in:
Coaap:url•Name I6.'INNER CASING OR TUBRiG$ p thermal clasxd-load_
FROM TO DLANIFTER TftICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 6r. sew-40 PVC •
fist aft applicable well peniiits Oil.County.State,Variarrce.ItyaUM err.,"
R. ft. in.
3.Well Use(check well use); 17:SCREEN
Water Supply Well: • - FROM TO IMAM ETER SIDTSIM THICKNESS I MATRRIht.
°Agricultural ❑FlunicipaliPublic 5 R. 15 ft. 2 in olo scH-4o I PVC
EIGeothemtal(Heating/Cooling Supply) °Residential Water Supply(single) fLft. hr.. I
©lndustriallConuncrcial °Residential Water Stipply(shared) I8•GROUT ._, _
FROST TO ' MATERIAL I EMPLACEMENT METHOD&AMOUNT
Elimination 0 ft. 3 ft. Portland Poured
Non-Water Supply Well: rt.
ISI1rlonitoring 0Recovery'
Injection Well: rt. ft.•
AAquiferRecharge AGnoundwatcrRenrediation 19:'SANDIGRAVEL PACK(if applicable)
FROM TO MATERAAI. EMPLACEMENT METH011
ElAquifer Storage and Rccovcty °Salinity Harrier . 4 ft. 15 ft. Filter Sand #2
❑Aquifer Test . ❑StormmtiatcrDrainage ft. It.
❑Experimental Technology ❑Subsidence Control
20;DRILLING LOG(attach additional sheets if necessary)
DCleotlterntal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(Mar.hardnea.tolA'rncktrryc.";xstn sire.c1r.1
❑Geothermal(Heating/Coolina Return) ❑Other(explain under#21.Retua►l sl 0 R. 5 ft. sandy grey fill silt
5 ft. 11 ft, silty clay black
4.Date Well(s)Cdnipleted: 7-13-23 Well ID#MW-6 11 ft, 15 ft, sandy silt white/tan
5a.Well Location: ft. ft.
Watson's Grocery ft. R ►'—ir� .t
Facilityt'0rrnerName Facility IDS(if applicable) R. ft, (;
102 Wards Rd., R, ft.
Rose Hill, NC,, 28458 AUG 0 7 ?tJq J
. Plnsical Address.City.and Zip -"21.RE.RIARKS r.. 1 ?rr-•. ;.:;,;'- U
Duplin Bentonite seal from 3-4' �` �atllr<+�r�l;? 1
ConWy Parcel adetairie:diun No,(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(If men field,one'Moog 1$-Safnelcad)
N ,jar 5'cottg 7/16/2023
Signature ofCcitilicd Well Con for Dale
6.Is(are)the well(s): X1Pennanent or ❑Temporary th•signing Ma rani.I hereby certify that the well(sl was(Here)cans'turfed iu a..orrlmwr
with 15A NCAC 02C.0100 or 154 NCAC O2C.020011 Well Cotrstrartfon Standards and that a
7.Is this a repair to an existing well: DYes or II No copy ofdik rcrond?tas&Tit proritled to the Ica,onager.
If Otis is a repair,fill ear4•70n71 wellcotu7ntcdon btforaurrlon and a pfabr the moire of the .
repair wider It21 remarke.rrcliin ar an the hark of this farm. 23.Site diagram or additional well details:
You may use the bad;of this page to provide additional well site derails or well
8.Number of wells cottstnteted: 1 construction details. You may also attach additional pages if necessary.
For tnnitlpli iriferrlon or rwrl-»rarer supply wells ONLY with the same construction,you can
.submit anc form. SIi11l41iTTAL iNSTUCTIONS
9.Total well depth below land surface 15 (ft,) 24a. For Alt Wells: Submit this font within 30 days of Cpmplction of well
For minidisk walls list all depths ifd(ftivent(cranpfc-3@20P'and 2@ WO) constniction to the following:
III.Static water level below top of easing: 11 (B.) Division of Water Resources,Information Processing Unit,
If water level is above casilt„,use"+" I617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter.6" (in.) 24b.Fay Fn"jcction WS11y ONLY: in addition to sending the form to the address in
24a above. also submit a copy of this forth within 30 days of completion of well
12.Well constniction method: Sonic construction to the following:
(i.e.auger.rotary.cable direct push.etc.)
Divlsiots of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a Yield(gpm) Method of test: 24e.For Water Supply&"[njectioon Wells: •
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: well constriction to the county health department or the county where
constructed.
Form GW-1 North Carolina Department of Enviroturnm and Natural Resources-Division of WaterRcnoutm Revised Auggust2013