GW1--07236_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD . ‘ _\..1) • Far[lima I..4c PIMA':
.This•fonn can ba Rscd-fai single ea multipb walla •- •
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•I,Wat:COntraettir hiftirmationt \kr\\ "e\Q • . . . •
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14:111TATERZONES:2 - • i ' - . ..
Robert Miller PROSI 'TO DESCRIPTION!' •
Wc1IConlmOor NUN. •. R. - ft,
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ft. • i i . , •
.2 675A • ft: -
NC Wc.13 Contractor Certification Number :15-::OUTER:CASING trtirlituttgiiisidn'alsOR:LINERtirin-flblo't`.._..._ ,
nom • TO •i DIAMETER ! 'FIRMNESS - ' -MATERIAL
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SAEDACCO . , . -E3 ft... . .56 .ft: 2 - lin: Sch 40 PVC . .
C('Milliuty.Maiv.. • ' --I6ANNERCASING ORTINIING.ikeddieiMil doEid-Inap),-,•• _. . .:-._.. -
- FROM • -TO DIAMETER THICKNESS MATERIAL• •
.2„Well ConstruCtion Permit 4: • •n, ft. •',•'In;,
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(foRgaiijkabie tTlidis fix.tbamy.State,ireiriaare;Nectirit i41.).
ft. • 'h.' • t 4.1! '
. . elrIt?It.1.*(ek*Ii WO R.S01
17,:SCREEN-. • •• . - . •' - . .
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Water Stipply,Well: '''• •vnum 1.70 -DIAMETER I.sLOT Sin TIIICKNESs -.MATERIAL
• ' 56 1i: 66 ,l'I!' 2 ' al. 4 :010 Sch 40 • Pvc . . •
• pAgrieultitt* . . . . 1;10thidipal/Publit . . .
-ti' ' M.. in. •
liGeothermal(HeatingiCoolingSupplY) 1:IResidentiat Water Supply(single)
• • Clitidustri*Cortuncrcial • - blIcsidential Water Supply(shared) -
EMPLACEMENT METHOD&A3101.MIT
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D iniOaLion • ' . . . . _ • - 0 ft. 4.9 ft, Portland Tremie•
Non-Water Stippty WeR;-., .•• : - • ,• '
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..Monitorii); • bliccoverY . •. , 1 • , •
, •Injection Welt; . R. ft: • , -
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ClAtiniferRCOnirge • -IZIOraundnuter RckdiatiOn • -. 492•SaNunGttAvELPACK ritiiiiptkant07-•-•--- - -t•--...--F,•F- - ,,---•--;7 —-:-....,- . •
.- • • ., • • 'FROM TO ; • MATERIAL • ESIPLAC'EMENT M Elmo n
*Oiler: tora,geao.1.1.*ivelY- ElSalinity Flzittict•
... .. . • . 53 .ft;-• •.68 ft. Sand c ' #2 . . • ' . '
C4WROT76T EIStortnwater Oraitingo• •
-ft„ •ft.
tlavtrinlcntra!Techr101PgY . 4§IthsikixO Control .. • •
• :?IniiDRIILIANG.LOGlatlith,sidititionlitiheeliiiiicietsasil'- . - •- '' ' • . •
-. . !Aconite nua.t(Cli*d Lool) tinacer- . .PROM •TO DESCRIPTIONtor.liaMaciiVitiCRDIK0-151TIPe.titi
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13Geotheutial(Heating/Coding-Return) ClOther(explain under int Rethinks) ft. ' -ft. 1; ...----:.L.,i.:il. if k_L...',/
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4„Date Well(s)Coutpletedt•10-11-23 ..-Miffl nitt OW-53 1 N )V 4) 8 2023
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5n,Well Location:. ,
IL ft. :'IM:11-;77-2;:.i.7.-1 f-'rz:v.7,1,45,-;-,z9 ill-TA
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FaciIiIpOiuRrNaluc. ' Facilily ID (if appiiFabjci• . .• R. - . ---.—
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1248 Bill Hall Rd. , Fayetteville, NC, 28306 . - ' ft. ' it. • . , F •
. . . Ploileal AO*City,and Zip :.2.L..,RtroARKs: . " . .
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Bentonite seal 49'-53' • ••-
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CcuclE' • Pareti Itionliticatian No,(PIN)
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. 5b.4•atilitdc'aittl Ltingitistle iirdOgniminutcsticilthds Or 4CcirniiI•dOrecst 21,eciiilleafinn:-
6TacII Salt";01; Ialang,,is-sima)
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-Is'• • W ..,:k20,44, . te, 4407- !.. 10/11/2023 .
Signatura cfg.'.4c ..;:x2 •"crelbEiz.-;,r, :k"...4: Dam .
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6:IS(Art.)the well(s): 53Perinaitent. or EITeinporad • signing.thLt form 1 herd)oroXv Mai 14 ir410)wr florrel cw•Innith4.11/,Eim•ordance
with/54-Ar.C4G 02C.0 1 Oil at-1,t1.ArC4C;02c.0269 War Conititicrion karsiards ansdihar a
1.4 tins iijr,0*-'01 an e;tistingirc111. ElYes or 011No• 'r431tv of a:UT ircpni itds fit-en o onside()!it Atwell oiniei,
.ifrhtsIto rvalr,fill on iwilinq Ili,:eonstimiotshtfOrmarlon mist e.tplaht the nature of the . • 'r.
repair torder#21..nernOrissimon.0i.al stir hark°MIN hint. - ',2'3:Site diagram or additional wed details; • - •
You tuay Use the back of this•page:to:provide addidonal well site details or Welt
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il.•Nittuberof wells Coitstriartedt 1 . . cousin:talon tietniis:•You mai alstuatiacit additional pages ifnecessaty. .. • •
• For nuadpfq 1mfrm/9i!or i-wa.r.et 1.apply 1...,//s ONLY with the same reatstri4tion,}V1.4 CO • . ; . . • ..,
' $21011/l.rnlifery.i..' ' ' ' SUBMITTAL INSTUCTIONS
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9-Total well deptli beton-land sn_rfaee: -•66 . (ft.) 24a, For All Wells:.-Submit this faun Withirc30 days of completion of well
. For oinillee'weirs liar all depga it dtfice'reni ictotopte-3@200'(loin@ 1907 .cotisliuctipti to thel0119Wintt . I
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110..S title water level below hiji.of eaSitt (1.) bilVlsitin of Water Resoutig.s,Informatitin Iiineessinp,Unit, .
Itwater.live!ft&ore,easing;file"+" 1617144 Serrice Cdifter,RaltiOOJC 27699-1617.
11.liaretud.Cdi:imeter:6 . (10 24b.For Inilectloo Wellci ONLY:.in addition to sending the.fonn to the addiu in. • .
• 244 above,also submit a,copy of this forth within 30 days of coupletion,of welt
• • it Well coustntetion method: Rote-sonic cottstructton to'the following I" .
(La. rotary.'enhle.l.diiect nush.etc., •
IHVIsion of Water it .es6gries,UntlettiOlutd Injeelkirl Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service:6,11er.Roleigh,NC 27699.4636
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• For-Water Stroh-&InicetiOn Welts: . .
• 13a.:Yicid(.glim). -•Matto il'of test: - •
• Also'inbtitit One copy of this form'Within.30 days of cOtutiletthit Of
LIlt.illshofeetion type: A.nitiOnt: well constitution to the.collet"'iieltlyclepOrtment of the county.where• • '•
constructed. •
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• - Fenn GW4 North Carolina Lk:Tornio of Environment*Natural Resources-Dividers of.Waier RrzOir5 Revised August MB.• •
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