HomeMy WebLinkAboutGW1--05747_Well Construction - GW1_20230905 1 1 ,
WELL_CONS' TRUCTION.RECORD For Intermit.*pNE.Y:.
' Th4.,formeaRbOuseil fair:sin&ei multiple wells. -
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1.Well-Centratetoir htformatiou: . . . . ' •
•:-1 4:WATER ZONES - 1 • . . . .
Stefan Smith FROM TO DESORPTION
. Well CoiftnitOr NOMe. ft; ft. I I
ft. ft.. I - • • • '
3576-A
•:.'ISd'.OUTER CASING(Mr'fouttkitsiertietisV OR LINERtitaii-tiettbk)t ":_
NC Well Contractor Certification Nturher
FROM To •- "DIAMETER THICKNESS ' MATERIAL
• SAEDACCO .It.: . It.- ' 1 tn.
Comp:a-Name- •
' ..t6::INNER CASING ORTURINGtiOtheirmd ekikil-loOlip•,'., .,...- - :
FROST TO ' DLAMETER THICKNESS ' MATERIAL ..
2.Welltonstruttion Pertait14; - 0 ft. 6 ft. 1 !' 1% SCH-40 PVC
Lille apii(icithre will peinr14ete..C9uriry...51phi,Variance. ,Nertitil eted•
ft.• ft. i' . in• •
3.'Welt Ilse(OR:pi:400SO -17:.SCREEN ' . • •
''WaterSupply Well: FROM TO DIAMETER s rt rr Sin. 711100 MSS ' MATERIA L 1
6 ' ft: 16 B. 1' 64 ' .010 SCH-413 PVC
• ElAgricuingai cRannicipOttbile • . ,
• ft. I ' ft:: •in. . •. .
C3Cretitermal(Mating/Cooling'Supply) .1:1Resideiniat•Water Supply.(singlo) . . . .
ClindustriallCommercial CIResidential Water-Sup*(shared) . -FRom ,,i0
I MATERIAL ,EMPLACEMLNT METHOD&AMOLINT-'
Elinigation• , - • ft. ' ft.
Neil-Water Sp pply Well: • • •- . . .. . . . .. . . --
ft ft' ,
55MOnitoring °Recovery ,, . . _ : - -• - . .
- Injection Well: n. ft.
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lI Aquifer Recharge lideMindwatcr Rentediatiou ,,/92SAND/GRAVEL PACK tifapplicabter - - - .-., ---• . " . . -•7,, ..
•... • -, .,... -,. . . ., . ,,. li ROM • TO al ATI:312AL • •. EMPLACEMENT METRO a '.
El Atinifef.S10111ge mil Receiver). .pSalinity Harriet, H, ft. . 'i
.... . .
El Annifci Test- CIStennwatci Opining;
..,. . . . .ft.,-
CIEVerimcinal Tseltrudo& CISUbsietenceCoMml
-,..lit.'DRILLING LOGIaltach addindfal tweIs If necissaiSi• . • • . ' ,
. .11.0tOtherrinti(Closed Limp) 13ttaCer. morn,- To • • DMCRIPTION lolor.hardimm.millinick 0 oc.cstin,.air,de.1
..
OGeolltennal tticatineiCoolitti Return) Mother(explain under-VI-Remarks) .ft. ft.
4.1tate Well(s)completed: 8/17/23 *V&,g_TD03-1
It. -
• 5a,Well Locating: . .It. - •It . ,
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• ' 4) 5
Forest Oaks Circle K ft.. - fr. . SEP 2023,
,
ticilityMirtterNamO • Facility 115710eapptablei. .r4 ' ft.. ' ifttolTna&cn pr",c,,se6, :.
• "'" uflo tin*
5324 Liberty.Rd., Greensboro, NC, 27406 . ' , - ft.. " ft,. . " INA:iti.ILMJ • '
PiOig1111:*leFs5;ciLY-.04 PP' 'It:REMARKS" - . . . .
Guilford Temporary well for grab sample
. ,
Cooly , Porvel Iriitilillealion No;(PIN)
I.,illitirda.Onittritigiinde in degrcesfeninutestseeentIS err*china deo*: 22:CertifiCatiorn-
Omen SOW,'one latilo •Wiliienl) •
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N -
W A';Sth4' ' 8/24/2023
Signat of Ce..fled WeR Conn:140r• Date
6.Is(at)thenell(s): ElPermaitent or iiTemppraty" 4 Aigning gar ,fqxm..1 hereby certify lbw thv wars)war(wel.e)eunyirifek4 IttjtcCardir71Cr
*jai 15e1 NPIC 02C.ploo or 15ANCrIC n2C.Q200 Well Como-Or/ion Simko.*and rbor d
7.Is this a r.Lp4ir to an ciiitigglyellif pVcs or ElNo. - . evirtFofrist:f recOni!oak Ikca prorlded fa.the sir li Ow!iir.
-If rh(s:11 a riimIt.tal fiiir:koo0 leaf eononrcriern hiformacion arid(i.siitabi the woke of air I. '
itipair touter P21:renuirks'.mann;or On de bark of ads form. - •23:Site diagramor additional wide tletaits:
You ma k use life hack of this page iri,provideladditional Well site details or Well
ft-Numb erof Wells Constructed: 1- consnuction details..You inay aLsO attach additional pages if iteCeskny.
For mid*lirdecrian'or ram-veer supply kegs ONLY 'ithi rly saw complain-on.,yon exra
FliNlli(ci, farm. - -• St11181ITTAL INSTUCIIONS i. .
9.1'otal Well depth below land mirfacei lq (It.) 21-a..For All Welber Submit this'fortit within 30 days of cempteticin of well
For arotapIi frelltliar ail OVA'ifillprenr lexanipfe-362)21Kr an41.2@ WO) constmetiou to the folloning: - I, '
10.Statie.Water led helew top of ming: (ft.) Divisn of Witter Restnitrceii,Inforthation pineessitiy,Unit,
If wiikr Wel ir above costa*i.ae."+" • 16,17 Mail SerViee'Cinter,Raleigh,NC 27699-16 t7
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11.Borehole diameter:2-.25" -(ia,) 2lb;For tjtjection Welk ONLY: In-addition co-sending the font'to the address in
24a ahaVe.also submit a-copy of this hurt within 30'days of completion of Welt
12.Well construction metited:DPT • • construttion tote IbIltiWinit- ! I
(Le.anger;ntIary,cal>le,alma rUsh.cre4 I. , - -
DIA:Ilan of Water.iiesources,Underground Injection Control Fragrant,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Catter,Raleigh,NC:276594636
24c,For Water Supply tic!slicedIt,to Wells:.
13a,Yield-(gPra) Method of tat:
• Also submit one'copy of this ItOrtii Within 30.days of cOnipletiettof
13b.Disinfection.typet Amount: well-conStruction to the county itealth department of the county where-
constructed.
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Form GW-1 Nortkoralina Department of EEVIIDEIRCEI and Natural Resources..-D;yision of Wale Rotrom Revised August 2013