GW1--05806_Well Construction - GW1_20230912

WELL.CONS'FRUCI'ION RECORD Far tciiw1 Use ONLY:.
.Tltts Canaan be ussd fur singings multi*wells
l.%`'c11.CantrttctnrInformatiott:. 1 , .
-4JtWA1'ER:ZONES .- • - . .
Chris Ruffer FROM TO DESCRIPTION
'Ka Corartttor Name. ft. ft, t 1
4223-A ft. ft '
NC Well Contractor Ccrtilteflion Numb cr ',tS:.OUTER.CASI?G'fi iiiuTlt:eisitsrt°!sells'IORL1NER'(lraplllcgbk).-' ._
FRo31 • TO DrAMETER 1111cliNESS ' STATERTAL
SAEDACCO • .ft. ri,' In.
Conmany hunt• _I6:INNER CASING'OR TUBING J1;eaibaimaf'ctuicd-lni j!1" -.- -
FROM TO . ' DIAMETER TIDCKNESS MATERIAL
Well Construction Permit#: 0 ft. 5 ft. 2 .'In. SCH-40 PVC
L Otill applicable rcel(prrmfho(he.County.Slate,Variance.Irfaliat1 rr�:) - — - - _ -----
tt.• rt. • in.
3.Welt Vise(Chtxl:Well rise): AS:SCREEN
Water Supply Well: - - FROM To I tnAdrET!CR ' SLOT Sins '11110Xnr s I INIATRiumt
CiAlgrt iiItittal DlvftintcipVIl/P111)lic• 5 ft. 15 fry 2 ill. 010 SCH-40 PVC
©Geotltermal(Ileating,'Cooling Supply) ®Residential-`'later Supply(single) II. IL I' -in,
•
"' GROUT'''. . TER_; - -..❑lydustriaYCommercial ©Residential WatefSupply(shared) FROM70 lAth
EMPLACEMEST 3IErrlOD S AMOUNT
• ❑irrigation' . 0 'ft. 3 ft. Portland Pour
Non-Water Supply Well: ft: a.
t Monitoring fltccoveiy _
Injection Well: ft. ft.
<JAgnifer•Rccharge DGtottridtrttcr Reincdiation 15 SANDJGILWIIL•PACKtlrulyiucabter_ - - _--- - -
I'ROM •TO I MATERIAL. R\IPI.ACIIME-NT Huron
• DAgnifcrSitiagc atrcl!tern.ety DSalinity Ranier 4 R. 15 ft. Sand I, #2
IDAgnlferTcst ❑SlorniwatcrDrainage ft.. it.
❑Exl,ctinicntal Technology DSnbsidcicc Coniml •
t, II:DRlLL1l1GLOG7aitach'additional shcctsifneeessar l •
•OGedtltemtal(Closed L1iap) ❑Tracer FROM TO DrSCIVlf•11ON(t»br.lninSacr,w Wai k Ow,min sam(lea
❑Gt otltennal(Fleaiin 'Cooling Return) ❑Outer(explain under#21 Remarks) -(L i
t •
tr. rt. I 1
4.Date Wefl(s).Courpleled: 8-15-2023 Well WNMW-27R ft. See GQq - Noted '
5a.Wo11 I:ieattan: .IL rt. , t" t t • E"
Holcomb Creosote Site • ft. - ft. SE-Ft-1
7
LI
. •Facilit}•rfl]n•ticrNaluo - - Facility lD11(iCapplic:•tble). R. ft. S`EP 1 2 1023-1
5016 US Hwy 601, Yadkinville, NC, 27005 ft. ft, lf)ft7i'TfeltIC t ,�^� e1 URA
PIVs.i^,atl-Addrxst.City..an d Zip Ir.REMAHXS'. . .• . - .Dili v eo,..141 -
Yadkin •Bentonite seal from 3-4�
alum). Parcel IdeiIittcatiou No,(PIN) 1 ,
Sb..Littittidcand I,ongliude in degrees/minutes/scconds or decimal degrees: 22.Certification:
Of melt troll!,one IaVI tag ls.sudtieicid)
N W - Chris- 'Buffer 8/20/2023
Sigrut io of Ceiti1led Well Collimator Date
6.Is(tire)the well(s)t SlPennanent or ❑Temporary (Ig signing Ibis faim..1 hereby rerrife chin the a•dlrs-1 Nis(NrreJ evartr wi d Lit;accord/mice
with FM,VGlC 02C,0100 or 154 NCAC 02 C,U200 Well Corrahr,eUon Srond-rats and char a
7.Is this a repairtir an eiistin„well: �Yei or pNab cc�.of Mir:ectinihdstirea T,mvGk M rt row1,n:fly.nur,
If rhls:ls n ripnlr.fill(Err Annul n ell eorurrurthiti hpgroutrlri,t,mrl,itploht the;more of the
repair router 3'21..rcenarkssecuma or cut the barkaf this fornr. 23.SIte diagram-or additional well,details:
You may use the back of this page to-provide'addiliouaI well Site details.or Well
8.hntRher of wells( ustt-neted: 1 - cousuuctiait details, You may Asia attachadditional pages if necessary.
For mailrlple Iaje rlon or ontt-uaaer supply wars ONLY irJth rhe.sauteca,rstrucliun,you obit $1J1114ilTTAL INSTIIC-TIONS
srabuur one form.
9.Total Well depth bele*land surface: • 15 (ft.) 2.ta. Fur All Wells Submit this farm within 30 days of completion of well
For mad* M 11srrel depths ffdi,Ih•rrnr texampke-3@?00'and.26,MT) consiniction to the foltoningr-
10.Static water leiel below top of easing A) Div/shin af-Water Resuu'rces,Information Piucessing Unit,
if wake la Ge!ll'above cuslag,ose"+" 1017 Mail Scil ice Center,Raleigh,NC 2 7 699-16 17
11.Borehole diameter.6" (in.) 24h.For infection Wells ONLY: In addition to sending the form to the address in.
24a above. also submit a-copy of this•faun within 30 days'of completion of;Mil
12.Well construction method: sonic construction to the following: I;
gig.uugce rotary,cable direct prsslc c(e:} I • ..
Division of'Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Malt Service Center,Raleigh.NC 27699-1636
;
•I3a.Yield�Itni) Method of test:__ 24c.For Water Supply.St Iniection..Wells:
- Also submit one copy of this;fdrin}tvtthin 30 days of cotupletioit of
13b.UisinlitiKiuu hpe Amount: well construction to the county licait€i!deportment of the coitnly'whore
constnlctcd.
Farm OW-.1 t.enit Carolina Dcpanment.of lnt'iroiunctn and Natural Resources-Divfs1on of Water R'uttces Revised August 2013