GW1--07713_Well Construction - GW1_20231122

WELL.CONSTRUCTION RECORD
Internal. Fox Internal ilsc ONLV: ,
This foancan.bc used for singraot nwliipk welds. \
1.We11.Conti:tctoe Ittfminatlott: \.n . ; .
i4:WAT}.'RZONES' .'
Stefan Smith rY �`. !'•WWI 'TO DESCRIPTION
Well Contractor Name- • ft. ft. I
3576A It. fr. f
NC Weil COmuactarCcniftcitionlrwrlter tS:OtITER CASR'C(fui iaufli rasei0 cccOsti'ORLiPiER'llf:tp"ticablc)%
FROM I TO DIAMETEiR'- THICKNESS MATERIAL
$AEDACCO 0 _fL 130 ft' 2 1, ' in. SCH-40 - PVC , '
1.(;onipmirName, <16iINNER'CASING OR,'I HING.(gpetheiMat'ehEtd4e+Onp '.- -
FROm TO I DL4.Sit:TER TRIMNESSMIATEIUAL
2.Wefl Construction Permit is ft, . ft. ,io. _
Lirr irll applirpblr.roll papa)*(Lc Costley.5rp:e•Varicose.Iryedo%rrr..f -
ft. to im
.W..elt tine(checl:%hell rise):• 717 SCREEN - •
Water Supply Well: - -_ FROM 1 TO DIAMETER' ;$LOT SIZE THICKNESS I uaTERrnr.
[lAgricultutal DiAtinicipaliPitblic- 30 ft• 40 it. 2 !n 010 SCH-40 PVC
DGcolliemtat(Hcating!CooIhi Supply) DRcsidenfial•WaterSupply(single) ft. I -it.. •i"'
Dhidustrial/Conmtcrcial DResidential Wnter.Supply(sitated) , t8i t;ROilT .0 :_:-- ._--- - -,- _-_ --- - .- : _
t?mO�r TO. MATERIAL 1 EMPLACLIILNT Atrium)&AMOUNT .
Ohrigation 0- ft. 26 ft..- Portland Tremie
•Npu�WatcrSupplyWelt:- R. ft. . . ' . - ._ .
•l Monitoring IDReco}ety ..
Injection Well: it. it. ' i.
DAgnifcrRccliarae EGmundnaicrRenicdial ion. t9s1ND/GRAVt LI'AChrir:gipuc rite -= .-
'56RO�I. i •To- MAMMAL ,EhIP1,ACtt:VEN•gr.TElOu .
• EAgjuiifcuStordgc and Recoil ry EISalinity Boma • 28 R. 40 U: ~Sand #2"
CI Aquifer Test DStvrnitt'atcrDrtinagc ft. (t.
❑t tirC[inncntal TcahnOfo pSnbsidcttcc.Caldrof f2o•pRILLiNGLOG7attseti additional sheets -ssani•
OGeodtemrll(ClosedL•oop) . . . ,OTracer FROM'- TO ' DESCRIPTION(color.hansne .WIVi,icsxtK.vrihtv?ettat
1]GeOtl►eunal(HealinrlCaol1nt Return) 0Otlter(explaiu under:#2l Retuatks) 0- .ft. 4- - ft. Silt''sand -
4 fir: 40 YL Sand,
4.DateW• elt(s).COmpleted 10-25-23 Weil:ID#Ri-Z4Wo9d t —'>—� N,_
54.Well Limiting: .ft. ft.. -
• NOV 2 2 2023
Greenville-Utilities Commission ft.- ft. .
FacilitylOn'acrNawe Facility 1I514(lfapplivablc). 7,
801 Rumford Rd., Greenville NC, 27834 _ ~
r - ft, ft. �.
PlosiridAifdipss.City.airdZip - `2"Eh I Rks- - ,
Pitt •2 foot bentonite, seal (from 26 to 28'
Cuutiiy S Parcd Idete tttemion Nu:(PIN} , (,
Sti..I atiludeanili.ongftirdein degrees/Minn tes/sccontlsor"decimal degrees: .22.Certification:
quell fidid,one Iatflon i sidfiiienl)
•
35.631246 N 77.363238 -w - 6r ./ Y .. • 11/8/2023
Sign?)ofCcY'.rOedWellCaiitmcto'• - Date
-- - I.
6.iS(:tre)lhe:aell(s): xtPetmauettt or ❑Temporary jti•rgning ihi.t foim..l hereby rcrg0:01ro Mg waifs)mar(tsrre)way:rue-red in.wean/mice
with'151 NOW 02C.0100 or 154.NC1IC(12G!0200)fell Couatr,rrioin Sraudurds and llsm a
7.Isnthis a rett:tirto an ciistiogwell ElYe .Or ®Nu tojtix•.ofrlilr:rerorihncI cn provided mobs.%Ili oir .i4;r.
If rhrs.lt a rrp:r!r.fill rni;I,reLi17J ri'el1 r10 orn(C11Dr1'hrfororario i turd explauli rl4'luirive if the +•
repair wrifrr sZl:iemarL•s s'eafml prim the burl Of this form. 23;Site du►granr or additional Well delight:
You may use the back of this page to:provide additional well site details:or Well
8.Nrruiberof Hells constructed: 1 ,' • construction details. You inoy a�aftacliadditional pages if m.icessary.•
For nrufrlplc.htfec:ion or roixn-suiu r supply ir'eils ONLY wJth rho.san/e colrstruetiwr,gait con •
sobniitOrie farm. - .SlIBMITFAL 1NSTtJT1ONS 1
9.Total Well depth bit*Lind surface 40 (ff.)' 24a. For All Wain- Submit this'fann within 30 days of completion of well
For irrniriplcieeilslisr Oil&e'p ildifferrnriexiorptu-3@2(J0'arui.2@ll1O) consfnmationto the foltoning:
10:Static}cater level below top of casitne ((1) Uivisiun of Water Resource i,Information Pitieessing(nit,
• limiter lei.l is drove curial;ilse"••+" 1617 Mail Service;Ccntcr,Raleigh,NC 27699-I617
11.13Rrebole diameter.8.,25" (in.) 24h.Tor ijrlcetlarn WelkONLY: iln addition to sending the form to the address in
24a above_also stibntit a•copy of this form within 30 days-of completion of well
12.Well constric method:tion ethod:HSA construction to the following!
(Lc.auger,rotary.cable direct cash,etc:}
Division of Water Resou rces,;Underground injection Control-Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scrvicertattcr,Raleigh,NC 27699-I636
13asXrcld'(giim) d'fct)rodnftest: 24c For Wate'rSufiplv..ticinirctim dWelts:
Also submit'one'Copy of this'firth Within'30 days of completion of
13b.Disinfection type: Amount: .well:cifitwtniction-to the county he}lth department of the county where
- constructed.
Form GW-t Nonh Carolina Depanineni of Environment t and Natural Resources-Division of Water Rf orris Revised August1013
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