GW1--06713_Well Construction - GW1_20231024

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Far7rtctnal trsc UNT,Y:-.
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1 Wcii Contractor Irinforlttatloa'::
. .. .'14 ISATEWZONE'cl,.h.. -. .,rwaL.#....0 x`� �s .""a, to kz.= . . . . ",
Rich Lemire.. 1R0.1 To. DtSCtttPltOY' ";,
Wait.itxrie orr'an ? 3 5 ft 12 R:: 1•
-ft..:• fit' ( ,
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i3 OUTERJCAST�TG(for�uutd sxiiiiitls}OR_LR'fER:{it tin fleiblel" ', r -`
:I±TG:WIC.ot ctaeCc......tion2lniislicr -.VROMM•. ::pro . .or4es�r THICKNESS MATERIAL
SAEDACCO t4
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'YnOM' 70 *DIAMETER -THICKNESS`. --MA7ERiAL
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2 WstCosrtton•lerinit#;•N/A. NCDEQ State Lead.UST
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Liaal71ii bk eri peJm1 fi. .Gaviity;•Rait tntaane:lf`AO rfcl• .
. 0 .. :.1t.; 2... tt`; '2 in... SCH40 PVC,
3.Well Vt e e(c` e1.v.cll;ueoi: J f A y� .
ter Snpply.Wet • .. .. • VROM•: TU DLAitrTFR' .s. OTSITZ Tntociigs••t MA1TRTAZ
Oz grtcultutal- DMuirzipaUAlblit 2 rt 12 2 Ia! 010 SCH40 PVC
f 1'R idi iitiai t5'atet u sta o rt f. ,n;.
Dt leoli tal(Eieabng,Caoling p i}. a Ol} gi ).. •
ClIns[tisttlaUGomtiic ial tlResidentialWaterSllPPt:•(shan*d}': FRONT. . .Tg' • .1WATEBTAL -':EatPLACE rn ITMEOD4AMOUNT :`
Dint t oti:.: .. . ... o .tt'. 1 .•.,n'. PORTLAND . POURED
Nati•Water Supp1}:W.*0 ,:•
rt 1
t$fgmtonng DRctgvrr}:'
:WJectton Ye11% - xt.:: • ft:.. • -
[]A.i.Eud`erTtecharbc c Griotindtiwter ttciiicdiatton 19 SANDlGRVVELPACKaf apta.Fsbtt , R s ue ., -
-PROW,' . . .70' stATEMWL P%1Pl.AC1:%I Nt'MF•tHan
C)Ailnlfcr Storage and lti cos ci•: C1 0.10iiy Ramer: 1.5 II 12 f4.. -SAND #2
cI640feCr T it: • CJStarmii,BIcrDracn lge:.
DE.�penmcnl l9`c 1uioli16'.. AStlbstdencc Co>tirol.
` t36 DRILL1KatAG idiiieh addition t i ii if iecectiatt5 -_'
D40.ot14mwl...Cluseiiteop) C1Tracer: FROSt> m DesCRtrnoxteoloh_Ifitailm ahucuhae:tiskiiivc.elGl
oGSotbenlral(Eles tilgfCootitlg'Rettitny DOtlter.(e4lt►iti nild r gti t t>fatlts} ' 0 ft, 12 tt. Tr+N sAND
ft fi •
4 Dat4:wa )Cornpleted 10-.9-2023, j el1IDOM W-.6RR,.. ..... . /, ,$ . 17
4.7.114.:4 40iitkiif. UU.. ft: x.a 0 ;}
NORRIS LUV STATION r.
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2821:.NC-.41:,..CHINQUAPIN; NC,..28521... • ' tl.• • tt.•: a a•k .; `
PhysicntAddrtss.•Cat} nod Zip:. ;�-i:`Rti:tlfA7ti---..,.,---•-_-;;;-, �:" 1. ° '.e.
DUPLIN . .. . ... 3359003640,17 'BENTONITE FROM 1:0'70 1':5': '
t tfaotk: ' 1,'anel ttiiiti cattoallo:°.1 lNI'
Sb'•,T ttltadc nd.I.ongitade to degn es/n i7wtalscconds or declmul cic�rocs. 22.Ccrhf"lcatioia.• );
(iti tt field,iik 1 tUlotsy is Sfrificicutj. • '.
34.83288 - 77.82221- Kr tt.�'C�•.:. 10-9r.2023.
• SitmtuiaorCcm V,cltContrzwtoc TYsto•• • -
6 7s(inr)thesrell(s). Perriianent .or .:12Tetnpora}:' st gun rini ran There tuff rhnl tJae aril sl ivv tin rtP+f{nrFietX urrxcii+rlm�r
.. iitl iSA NC7.4Gf1ZC 0100 nr;15A NCAC 02C:02001Sell COitstt°.fctfwrStvn1o,Jsui itthat a
I Is this a repair to an;exixtmg well QYes ar (No`: :. t'�n°of thLi recarl.1.4 iT i p,in 14.J io hi.,t.kil m+;r'er:
If tlils is g rcpidir 0o.n 3arstvvr u ell raotrnfrtlo is ikiirrtitdvtr atut raplebi tlit•n rtrae of llir
nrpiiitoiO4,h1,rmnrkii:li tiam or.i ii,dig.bfx t of dJvs fora: '13 Site diagram or additional ti ell.detntf_k
Y611 n►q} use the hack of this page::o provide additional well site details'or lreil
S'11itntber'ofiretls comftivcted: 1 coucttocuoo di.talls `You ina}a1soattoch addiuonal panstf necessan.:
Pe.,6i rllrlt i ecilan w n i lfrner stipple art OiVl Y»4Ji die.amiie cbustruodonr Mn: ,. •
ii4ltniN on for.o - • • 1TUbii7`PAL MNFIlrCTiONC
4 Total etl depth belotrt land•surfaces- 12.. . (ft): ?:la::tor AA 4'etlx. Submit tius'fatm tiuhm fit)n i}'s of c:oinplettn°of*ti11
Por,akiiifr teens Isst irll iteprtit?!di trr v lennple•:{@ 209 z»ul 2C,10(r) • constuiction to tlo following .
1U:StatIN*Ater Icielbielow top;ofeasIngg 3.:5 •. ... . (it) Dlit.5lOnofWinerRcsoteree.9,InforatahotiPmcrrxingUnit,
,• . •':3617MYaSIsScntcc(:cntcryRailctgli:NC176991617
ijriiar�r/rt�rf lsvLoret+'itrr�Ole '}.' ,. ,
its 8urthitle diameter;8.2 5 (Sit y 24b $or Infection WeU ONLY :In addition to sending the.,fomt to'tb.,address to•
24aabbre. also'subnln a:,copyroI this lena within O dais of.cotupli:Eton of is ll.
12.:NVCII Construction n e JDd:AUGER 604:S40tloit4;tl followin
(Lc_ni,er rolaia cAtfle disxt P•. ctd}
,Division of‘froterResourccs,Underground Injection ControlProgrnnt..;
FOR WATER SUPPL Y E U W S oms:. 1636 MaiE.Seri kcc,Center.R3lelt b,NC:27699=1636.
134,Xteld( tm... ' tltad of test: 2dc.1 or Water Supply&Injextinri iYc1E1
.. Also sitbntit one ao,y:of this form rvtt)nn t0 d4sofceiuplelionaf"
iicll'cpnstntcbcfl to the county hgoith dcpattm,nt.if the.cotintty t.bcre.
31 Dlalafccaon ta» , , Ampunt.,. -
Fenn GW I' ltotth Carolina f cpn nrentof Em'uonment afrd t aturnlResowecs_-:Diction of WaleAE.50 s., Rcrlscd:Aiig10:24i