GW1--00167_Well Construction - GW1_20231229

1
WELL CONSTRUCTION RECORD FgrlrtarnalUsc;ONLY;
Thh form catibc used for.single Or multiple ncils' I
1.Well Contractor Information:
141- ATI!R'LONIS • I ,
Brian Ewing . . , FROMTO DESCRIPTION •
Well Cnnitactor,Neme ft. It. I I .
4240—B
:ft. ft. I I .
•
• tti•.MUTEft CASING(Inrtnulli�casednefls)OR.LINER(Mali lieabk),
NC Well ConuaGotCcetificationNutrlier
•mOM TO - I DIA1nr.TnR, THICKNESS. MATERIAL
SAEDACCO 0 ft.• 7 ft. 1. I' to, SCH-40 • PVC
Continuity Name 'IS NNER'CASING OR TUBING•(geothcrrnal c6osed-1o0lr ' •
. •PROM - - TO• DIASIETER! THICKNESS MATERIAL
2,Welt Construction Permit R; . •R,. . ft: • I :hi.
I.4.i all appilicobk wet t permits(ic.County;State,.Uariarv..14ix artelr.:)• O. i•
3.WellEse(ehecicwell use): • .I7'SCREEN
Water Supply Well: -- goof. , To 'DIAMETER• S rot stn. THICKNESS I MATERIAL
❑Agtieultiitnl. CIMur eipaLPub)ig 7 ft. 17 •R. -1 ina I '.O10 SCH-40 PVC
DGeathefinal(HeatinglCooling Supply). ❑ResidertiatWatcr Supply(single) • • It- ft. in.
®induslriailConmtcrcial C]Rcsidcntial Water Supply(shared) FRO I Q TO MATERIAL METHOD T1IOD SAMOIN1''
❑ittigaticn •. ft.' rt. i
I.
Non-Water Supply Well:
-. lighloni1oring •, . . i]Rccovery. ft,. R.
•
Ittjecllott•Weltr- : . .11, ft.,
DA.quifcrRecharge EldimiridwaterRcnicdiction -<t9:'SANDIGRAVEL PACK(if upplicibtc)
FR(HaI ' 10- MATH/UAL • E?AIPLACEMENT MtTrlOn
DAgaifcr.Storagc and Rccovcty l]Salinity Hama 5 •.R.. 17 ft.. Sand I, #2
. ❑Aquifci.Test • ❑Sioirntcatctu linage ft: ft.
I]E'ipctimcntal Technology ❑Subsidence Conirot- . . . . -
'2a;DRILLiNG'LOG(attach additional sheets if ncecssan•1 -
❑Geodtenital,(Clased Loop) DTrrcer. . • .FROM TO • DLSCRIPrION(rnbr,Noised:vinwkk0rk.prnnr4re.dr.)
°Combcnnal(Rea6RelCaoliva Return) 1:1011ter(e plain under#21 Remniks) '.ft ft.
ft.. ft.
4.Date WOO Completed: 12/12/23 Well iD#TMW-a 1 a 4 •ft. • II... , .,,L..,:,i' J ti` '
5a.Well Location: iL . . ft... D fi(. 2 2 G 2023
Wheeler's Grocery ft. ft.
.FactlityXlisa;rNmtuc Facility 1Dk(ifapph.ablc) R. ft. n" "::•`-',d a ^; .�� • 1.;;;,'
9385-A US Hwy 158,.Reidsville, NC, 27320. . .rt, rt.. L 1.�`'!'"�'~" 'J ' •
•
Pkiskill Address.City.and Zip' ,.21.REMARKS- . {
Rockingham .Bentonite seal from 3-5'I
County 1*atcei i kiaificaailon•No,(PIN)
Sb,L,htitiide and Longitude in degrceslminul�cs/secgnds tir ttecitnal degt•ecs: 2la Certification:
(true!!field,or tat,lotig tt stdncl id) i
N W Br a.n- Emil n,g, 12/20/2023
SigmtuieefCeitifedVicltCanitactar _ Dale
6.Is(are)the wcll(s):.❑Perinanene .or %ITemporan ' 'By signing this fomr,'I hereby errrify rluujrhr wel(.v1 mats(pen)cx aanrc•Ied hrar_eendamce-
With 15t1 NC AC 02C,0100 or 15et NCitC 02C.0200 Well Conirrert'oir Sraihlards and t1w:a •
7.Is this a repair to an existing well: 121Yes- .or KiNo copy ofMir reronl hos Nen proridrd to Me Tall owner,
- if rhls`ls a iepa(r,fall oaorkrroital rill coosinrcrlost brforourilon and rxplahr the tyrrire of die .
i-c s.irrinrfcr 021 rernaehs:tirt'tian or an the brirl of tit,*form. .23.Site dingl•am Or additional well details: .
Yau ma);use the back of this page M.pro►'ide additional well site details or rsell
S.Number of wells constructed: 1 • coustmctiolldetaifS, You may also atiacl udditional pages if nec:essaty.
For laalrlpk fnjecilon or non-roarer snpplr•trolls ONLY with the.sarne [e-mail] coo I
.subm(tono;two. SUBMITTAL iNSTliCTIONS.
9.Total well depth below land surface: 17 • ' • (ft.) 24a. For All Wells: Submit this Tana within 30-days of completion of welt
FornorillpleiicUs list all Arks'Ifdi,@•rrrnt(example-3@200'and2@100) construction to the following:
• 10.Static water level below top of casing: (ft.) Dii'isinn of Water Resources,Information Processing Unit,
trowel-level is above ca:hrp;ewe''+" 1617.1411ailScr rice Center,Ralei ,NC 276991.617
i'
11.Borehole dialectal 2.25" (in.) tab.For hideetlon Weds ONLY: in addition to sending the foal to the.address in
24a above..also submit a copy of this fono within 30 days of,completion of well
12.Well construction method:DPT - constmctlon to the following:• i
(i.c.auger.rally,cable direct.posh.etc.} I ' •
'Division of Water Resources,Undergrtlund Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cennc Raleigh;NC 27699.1636
13,T Yield(gym) Method'of test: 24e.For Water Supply&Injection Welts:
Also'submit one copy of•tius'fann lvithitt 30,daysofcompletion.of
13b.Ditinfcctinn I%fl Amount: well construction to the county health department of die,cotinty.n'licrc-
. consinicted.
FonnGW-L NnnhCarohnaD- r punmentofEtn'itattttrtuandNeutralR�tu _o ces-DivisionofWaterRtrtns Revised AugustY1)l3
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