GW1--07709_Well Construction - GW1_20231122

I '
WELL.CONSTRUCTION RECORD Far faunal Use t9NLi':.
This farm canbc'us•A for single or multiple wells-
.Wc1i,CoutractorInfortuation: - , ; .
qJ WATBRZONES. - ' '
•
Stefan Smith Fnom 70 nrACRtrRION -
Wc1iColiinictor-Nan,C, R. ft. I ( '
3576A •
r4 ft,
NC Well Cotdrnctor Certification Number • fSJt)tffER CASING'(for*ri fl-c i tIli-dficI OR LiNER(if ap Gcabkl
FRO51 'TO DIAMETER• - .THICKNESS MATERIAL
SAEDACCO 0 IL 6 , ft.• 2 1, I la. SCH-40 .' PVC - •
Comp utyName ',IC:INNER CASiNG'OR TIJD11NEa;1 e'ciihcfmii}cBuuil-do ._ -
FROM TO DIAMETER TWCE NESS MATERIAL
2.`Yell Crinstructirin PcrTuit#: f, ft. lit.
.1.4—i a mtili abkwcllprlmits.(i.r.Caunn.'Strd6.Variaore.lr1'erbt4 eruJ ff. ft, 1>r
•
3:Well_iJse(chcel:well use): :L7:SCREEN . .
\\'titer Supply Well: •
•
most i'To DIAMETER siATSWZ - initooss 1 M 4Tr oral, •
6 ' its 16 =f1. 2 ' !'r. .010 SCH-40 PVC
EI gtf.^ultara! CllLlfulieipab'Ptrbiic- -
I�CreotlteDnal(Heating/Cooling•Supply) ( Residential Water Supply(single) fi. ' ft,• in .
Ohrdnstrial/Conmtercial ®Residential Water•Supply(spared) TNzCROIff, _ .'•..
FRO51 TO. MATERIAL i EMPLACEMENT IIiETROD&AMOUNT-
El Irri i tion . . . ,., 0 •ft• 3 ft Portland Pour . •
-
Nqu=\YaterSupply Well: • _• ft. ft. .
ltMonitciring - GIlatt;mcty rt. ft.Injection Well:
OA,gaifcrRccliarge DCiromidwalerRciaedioiion t9.SAND/GRAVEL'PAC1(,ri ptle itel" :, „ -_ _ , . - - - _
.. :-FnOhr- 10' 3LtTP,RTAL EMPLACEMENT METHOD
oAgtilfcr-Storago and Rceoyety ' IJ5alinily HirricE 5 ' R. 16 f. Sandi #2
E1Agrnt rTest- ' IJStorni s,tcrDrt nngc
ri. 0.
C1>_Ypctimcntnl Tcclmvlogv 1:15nbsidcrscc.Cordml :21VDRILI.B\GLOG7atlacl'i.additiona1 sheets if aceccuin}
t Octit u:nnat(Closed Loup) Orr e,er Rion- TO ' - DESCRIPTION rmur.lmrdua;.3ididuttt trrc:'erad Are.Nut
OCuaihennal(Heating/Cooling Return) • OOther.(e!tplaitt under#21 Retuatt s) 0 .tL 4 ft, Slit,;sand
4 .ft.... 16 ft. Sandi -•-,
-l:Datii\Yill(s).Coniplctedt'-10-25-23 WeItmttRI-MWl)4 '^
•ft• ft.
5d,Well Liicatton: it.- ft
NOV 2 ? 2023
Greenville Utilities Commission' - ft.- ft;'
Facility,'3 ncr'taiu Facility ID#Of applicable). -- -R. '- - -ft, r, .• t ._�1_,!:-.1:,‘
801 Mumford Rd., Greenville, NC, 27834 • . ; ft, R. 1 ,
-Pin-Sicul Aiddress.City.and Zip '• -2t REMARKS-
Pitt • 2 foot bentonite seal !from 3 to 5'
Coolly Parcel t(1_utit}, ilon NO.(PIN) • i,
• P ,
5h.Lirtitirdc anill.ongftuifc in degiecs/minutcs/seconds aEdecimal-degrees: 22.Certification: 1'
• (if moll field;one lat,1or>t;idditI icimu) _
35.631988 N 77.362299 \V • y I. 11/8/2023
S'f to SiQnvi' of Cc:rGcd Well t;aiitrn;tari� Dale
6.is(:ti'c)thewell(s): KIPcnn rnettt •or ❑Temporary 1'
�'signing thilr jarm:,1 hereby�'ertijv�r4nt the.11'r1I{5'!krtY(Krtr!)rursrrirCferl br;u[Y'Onlanre
Oilh'1SA.KAC 02C.0100 or 111.NCAC 02C,0209 Weil Corsi/cordon Standards ernd film a
7.Is this a n:llair fo an existtn,,;well: ®Vet:or 10No- •rcjn'ofthir ieeord bilk been Provided r6Art spell!artier.
rh(s:dr a re 1r ill rote krz'Irvi IirOarnrmrctlon b onnasioa mid ca•(ohr the mauve o rile I'
reejwir wafer 0'21'remarLs':srctryn or on the bark of this form. 23:Site diagram or additional Well.details:
You pay.use the back of this page to protide•adt tiotial well site details:or Well
8,N uuberuf Wells constrliuted: 1 -• corisnuctlon details, You May llso•attach.sddiiionat pages if necessary.
For tutubdpkItifei.almltrt•non, arersupplyrvvUsONLYu•lrtirhv.nReteco:atnwtion Iotaeoq I' •
submit mie form. - Si BMIITTAL iNSTiJCT1ONS 1'.
9.Total Well depth helm-land surface: 16 • (ft.) 24a.,Far All 'Welts: Submit this.fmrn witliin 30 days'of completion'of well
For nrnlrlplr icdIr'list Oil diph-frdifjervnr(c.rmrpte-8@20W'trod 20100) 'conitnlction to Ilse folloising -
I0.Static water lei el below top of casing: . (je,) Division of•Water Remo rce3,Inforniatian Processing Pull,:
tfrrrater Mid le above cash;ese"+" 1617 Alan.Scr►•iecrenter,Raicig)r,NC-27699-1617
II.Rnrelniie diameter.8.25" - . (in.) 24b.-For Ilijection_Wcllq ONLY: 1 in addition to-sending the fomi to the address in
2daab&e,also submit a•copy of this form within 30 days-of.couspletion of hell
12.Well construction method:RSA -construction to the followine- i I
(Le.augei'rosary,cable direct gust.etc.) •
DIvCSfon of Water.Risources,Underground Injection Control Program,
' FOR WATER SUPPLY WELLSONLY; 1636 gall SersiceIC+'nier,Raleigh,NC276594636
134r.YtcJd(Om) Method of test: 24e.,For Water'.Stipply&Injectllfod.Welts:.
Also submit one copy' of this,form within 3U;daysofcatnpletionof
13b.Disinf°ection Pc: Amount: well constmetion to the county health department oe the county where
eonsitucted, I
Fenn GW-1 North Camlina fcpannunt of Em•imnsnaO and Nawral Resources-Dlti is ion of Water RMairon Revised.August 2013
1
1