GW1--07704_Well Construction - GW1_20231122

WELL:CONSTRUCTION'RECORD I '
Farttxcntal Use DNLY:.
This fcrtn can be-uscd for.singlo or multip)e wells.
. 11. 1t.Cpnti:ictoI!animation:W •
111.WATER ZONES,. ' - .- 1
Stefan Smith FR031' TO DESCRIPTION
WcflCoiitractorNatue ft. ft.
3576A fl. I IL
NC Well CoNraclarCcni(tc�tfortNuirlier :`r5'OUTER CASING:tfbr$isuttizcaird iiellstiOR LINCRYtfdppfle'ablc)'�
FRom' I TO DFAMETER TIIICECTESS ' MATERIAL
SAEDACCO 0 ft:. 6 (L 2 4 in.- SCR-40 PVC
CoasporName. :WINNER CASING'ORTUHING fgeottreirtial dial-loiiI -' -
FRO`r TO_ DIAMETER• TIRCKNE.SS MATERIAL
Con
struction nstruction Permit 1: • ft.. rt. • '
Litt all applicable well pc:razts(Le.County:SSta:e,Variaure,fryer thi e1_)
ft. A. !' ia.
3.Well else(checlh visit use): :17:SCREEN - .
Water Supply Well: :- • FROM. TO t DIAMF,TER ' srfrSiTh TIIICKNrtiS 1 a141RfIAL
Chtgricultuial °hlunicipal/1N ic. • 6 ft. 16 rt. 2 010 SCH-40 PVC
DGeoihenml(Hcating/Cooliug-Supply) 1)Residentiat WaterSuppiy(single) ft ft; • in.
. CliudustrialfCotuniercial ©ResideutiaiWateeSuppl}(shared) 'tarGR°UT-..., =° : ..
FROM TO. MATEMAL i EMPLACEMbIT METHOD SAmouNr
l7lrripition • 0 'ft. 3 ft, Portland IPour .
-Nau W itcr Su.pply ell: R.. ft. . _. . ,
Manitaring EIRccocry 5d ' - . .
Inject Igo Well: ft. 'II. , . 1 • .
17Ai(uiferRceliarge [1GioundtrticiReinediation 419'SANDIGILWELI'ACI(ir,grpticante .. _ - __: . , ___
:,NRO�I- 10 • M tTEItrar, ,RSIPtACEME,NT iILTIIOI1
• LlAgtiifcrStortgc and Recovery ClSalinfty R latc': 5 R.: 16 ft. Sand #2
El Aqufcr Test ClStonaWatcrl r iaage •
Al.. ft.
OExp dmcntal Tcclmotoey'• ESubsideocetantr l
::af DRILLING'LOG7adUeh.additional Oieets if aeceasairvF
OGea dieting(ClosedLtia)r} DTrlcer FROM•' TO DESCRIPTION(wbr.l,;,,vncta,stiOlmektpnca;ra5nShoHui
EGeotlternlal(HeatingiCooliugReturn) OOtlter(explain uirder.#2I_Remarks) 0 .ft. 4 - ft, silt I sand
4 fr.: 16' fL Sandi
'(.Date Welt(s)Comgdeted: 10-26-23 Mt&t NtRI-MW06 •
ft. ft.
5a.Well I:ticatlati: ..It, ft. '~' .- ) ' 1"ya :Greenville Utilities Commission ft.. R.
tocilitykillSocrNaroc • Facility log iifapplicabic), - -- ft, f'... j _• NC�' !i .a-20L.j
•
801 Rumford Rd., Greenville, NC, 27834 rt. ft. 1,- ;;-;,.,n 13:-,. ,v ,;J US
PIo seal Address:City.and Zip'• --11:RI lARf:S". - Li +,.„' '_;6 ,
Pitt 2 foot bentonite seal from 3 to-5'
County - Parcel Ida tirrealion No.(PIN)
5J Iattitudc.aaii141.10tulloindcgrccshainutcshhcctintlsardccimaldegrces:
(it nettfictd,otietatiIor li•s,dficicld) 22:.t"crtiticaNna:
35.631435 77.362453 �'♦r . l' / i, , • 11/8/2023
Sigma of Ce;fled Well Contractor, • Dale
6.Is(are)the'well(s); 70Penrlaitent. .or ETcntporary signing obis form.1 hereby rerilfy;thus the welI(51 V.TLr(rimer)ear4Irifrte4 hi aatenl ,ai.
1Guh 1501 NCAC 02C;O1(kl or 15A NOW fI2C.0200 Weil Coaatinednit Standards(yid that a
7.Ii this a nt lush to ad C\iititt4wcII'• f]ift :air ®No iojn'of;hk'record herb been pi nulk4 ioihe,n•11 order.
41 th(s.It n repair.,fl1 air kom iu ty 11 ao-ru-nnactloa ht foroier1bn aiul,aplaht die manure virile
repair raider t121_rernarks seriion or im the back of this forna 23:Site diagram nr additional Well details:
You may.use the barb of this pate to prot,idi:'additional well sire details.or Well
8.Ntuober_of wells constructed: 1 •coustnictiott details. You may Also attach udditioual pages if tecess.nv.
Foe maidpl¢heleerloft'tu-elect-Tvarer supply tells ONLY with dm.smRe eorrstruetioat,you ran - - i,
iubnutthI.fem. - -- SUBMITTAL INSTUCTIONS,
9.Totel Well depth betow-hind surface 16 (ft.), ,24a: For All Wcllsi-Siibtrtil ills feint within 30 days of contpterion of'yell
Forrnniltlple Welk flailydeptlai Deaflyere„:(e.rtu ple-3 200'tmd.2@lOO) cons(mction to the foftoning:
10.Statie water level below toll of casing By,) Division of Water Misnames,Information Processing(fnit.,
if many leiwi 1s above eaalog,we"+" I07 Mail.S iTice4ee:I:R r.Raleigh,NC 27699-IG 17
II,I3orehtite diameter.8:25" (in.} 24b;For Infection WON ONLX: 'in-addition to-sending the form to the address in
24aabovve..also sainitit It:cony-of this form within.30 dass'of completion of hell
12.Well csousnisetion method:HSA construction to the folloWing:- ( I
(Le.nigh iatary,able,direct push etc:) ! •
Rivislou of Water Resources,tJndeygruuttd Injection Control,Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Sert'ice1Centcr,Raleigh,NC 27699-I636
13:q Vicki '24e,For Water Supply St Injection Wells:.
( iTtrj li6tirod of test: Also submit'ore•copy of this'fort'Within 30 days of completion of
lap.Disinfection type: Amount: well coil tniction to the county colds department of the county where
. constructed.
Farm GW-t North Carolina Ilt'panweiu of Edelman cat and Natural Resources-Division of Water RF--au tat Revised August 2013