HomeMy WebLinkAboutGW1--06285_Well Construction - GW1_20230926 .
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WELL CONSTRUCTION RECORD For irrentil Use ONLY: ' '
This form can be used for single or tnultipk wells.
I.Well Contractor Information: ' •
.,Y srATTrRZoNFS
Scott Hunt, Jr FtROM- ' TO PEACKIPt1ON
Well ContradorName 11 ft. 15 ft, silty (sandy •
• 4561-A ft. ft.
NC Well ConiractorConificationNutrllei i . -'r1S,OUTER'CASiNG`tfi r.'iriiitti a ikdAtills)OR LiNER:ftfitn-pesbk)r .
FROM TO DIANIRTER' THICKNESS MATERIAL'
•
SAEDACCO .f4 rt.' ' I. Li.. •
Conmany Nanh :16:i R'C NNEASING'OR-TUBGnih IN ie'rufai cl iscd-laup`I',. -__.. .
FROM TO DIAMETER: THICKNESS \IATERiAL
2.W6lt'ConstIucihin rcrmit#: • o -II. 5 ft. 2 I 'ht. SCH-40 PVC
Lisf utt sppilirabre'fullpeaniis fir_.County,•Sune,Variance.ft}'s'bC%i(qr..; n ft., Iiu
3;•WellDSc(cheelctvelluse): ;:17St:RI:EN' , . _
Water Supply Well: -- • FROM • TO •DtAtmETI:R- stOFSt7]: TntCIKIF S MATRRiAt,
. Otlgricultival Dlvinriicipal/Publie. •
5 R. 15 •rt. 2 ill; oho scH-4o PVC
17 Rla Geotiterl(Heating/Cooling Supply) ®Residential Water Supply(single) . fL. «. in:;
• DindustrialJCoutotercial ®Residential Water Supply(sbai di), -PRO O TO MATERIAL. EtrPt lcESIENTMEIlIOD&AMOiINT
. ❑inipatian . . . . ' 0 '' it. 3 ft. Portland Poured
Noti-Water Supply Web: R.
COMOnitoring ❑Rccovery ,
Injection Well: ' R. ft,• -
®elquifcritecilarge -DGNutidtihicr itcntcd•ilation - . ?to:SAND/GRAVEL:PACK fit.atrplicabtii) _--•--- - -.- ----
FItOM- - TO MATiott.m. RsimAct:mE,NTmuutton
°Aquifer Storage.aid Rccovety (]Salinity Hamer 4 ft. 15 ft, Filter' Sand #2
17Atptifer.Tcst . '. OSiottmnatcrpmiikoae. • ft. • ft.
I71">petimcnlalTiNhntrl0g} OSnbsidcnc ,Canit>al -..262DR16L1NIG:LOGYattackadditioaalskectsiriteccssnni -
OGeotitemtal{Closed Loop) OTraeer - , ...FROM- ' TO DFSCRWTIOIYtiobr.uurarica.snnwkktroe.pain ewe,ttea
•
OGeothenual(FTeatineiCoolino.Return} DOther(explain under£t2t.Retuinks) • o :t!. 5 tr. sandy grey fill silt
. 5, -ft.. 11 R. silty:clay black
• 4:Date.Will(s)Canrpleted: 7-13-23 •We1LID#MW-6 11 ft, 15 • ' ft; sandy isilt white/tan'
$a:Well Location: . . it. tL 1
Watson's Grocery f4 ft, 'T^i-�W--r; 4
" t ti1L. 1/ 1,.d
Fuct7rty,Pwl crNan_'e. Facilitj•IDN'• (ifappticable} ' R R. . e ''
• 102 Wards Rd., Rose Hill, NC,, 28458
R.: tr. SEp 2 '0 023
Plgsical Aildiesc.City,and Zip• z21.REMARKS' - i,,:4(
Du tin Bentonite seal from 3-4. r'�
lRr✓' . ...-F11�
County Parcel Idotili&u�ddn No,(PIN) .
p'..w..�
56..Littihrde and-longitude in degrees rninutcslsceonds'or dceinial degi ces: 22:ocr tifirntnm: I '
. (tract!lid;em.l;thlerig is sullickid) i
• 34.819083 1, . -78.101020 w c5co 7/16/2023
Sigrnture ofCeitiftcd Well Con tar ; Date
6.Is(are)the wrell(s): iciPennunent or l7Temportti}
By srgnntg ahir Ann.f-Prerrbv rerlify On thy n•rl/{s'1 tsys•-{4:rni=citrstnrcParl in rxrotrldnor
'l i&15A N(tC 02C.01(10 ar/SA NCrtG'(I'C.0200 Well Co,rs(rrtiNou Sramdards-and tlxrt d
7:Is this a rlvyrair to an eeisting ivil: Dies -or HIND, • -opt 0frltif nc ol1h11af be6'1 ill-m.14ed 0.M.e'sltll owner,
•
ifafr(s:fs'oripalr,Jill avrkroirvi.oilfcotuinrcion.biforrtiotlou and i_l'pu iairlierurrure'ofrIlo.• • {' '
n•(iair ranter Pi rrrnrirLx srcIrcn or on the bad of iIis•form ' 23:S ite diagram or additional f eIl details:
You may use the back'of this page;to:provide addiiiotiat' ell site details or well
8. %nmlter of wills constructed: 1 consuuetlom details. You iva}also'iiltacii additional pages if necessary.
Paririahiple.btfeac,ton'tirnrui-ntirersipph ittrlKONLl.lriih the sainrcass_tritetiarr,vonrau ,
Nutpiiit.one form. :STiBMITTALTNSTLTCTIONS I,
9.Total well'depth below land Surface: 15 (il;) 24a. Isar All Wells Subinil.tlti4 furni Within 3(1 days of completion of Weil
• For inaltlphv ivr(lr'liir off depths If eliffi eiir((Aden?('-3@200'<ca12@(#91' - construction.tci the foilaningg:
10.Static Water level below top Of easiupi 1.8 (ft) Division of Water Res urces,lnfOrmati0u Pro essing Unit,
If Inner ktn'l Is'cbor!u casvt;;ease"+" 1617 Malt Strrice Center,ltalcigh,,NC 27699-1617
11.lorchote dianictct:6" (in,) .24b.j;'nr Toicstion'Welly ONLY:'To addition to sending the form to the address-in
lid above.also submit a•copy of this form within 30'days of completion of well
12.Well construction IDcihod: Sonic eottstiuctiola to the following:
(i.e.pager...iotar}•,cable-diner push.etc., '
• 'Division of Water Resources,'Uuderground Injection Control Prom...rut,
FOR WATER SUPPLY WELLS'ONLY 1636 Mai'Sonial.CO:nler,Raleigh.NC 27649-1636
13a,Yield(pot) Method af'tcst ' 'ram For Water Supply'&'fnjeelto f Neils:
Also submit one copy of this;'Orin-within 30 daysof Completion of
1311.Diiinfectiuu tire: - Amount: twat canstrnction to the county hCaith department of the cainily where
•constructed.
Fenn GW-1 Nonit Carolina t7:parinen i t of Eill tnnnrn1 and Natural Resources—Division of Water Recta Revised August2013
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