GW1--00447_Well Construction - GW1_20240116

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WELL CONSTRUCTEON RECORD For[eternal Use ONLY:
This foam can bcuscd forsinglc oa multiple welts .
➢:Welk Ciintructor Information: .
;t4LWATELt2ONFS'. I .i . . • . .
Rich.Lemire , FROM to '0ESCRIPtI4MN'
WellEenttaelorNanui R. ft, .
2593A ft. ft.. f ; -
NCEYdICanuacRirCcniftcationNutid,cr Ic OUTER CASING(for muI1l. wddnefis)'OR•LINF.RRfab fiestrki' '
mosi TO DCASSETRRI ! THICKNESS. MATERIAL-
SAEDACCO 0 ft. 5 ft,` 1 Ag.' 'SCH'•40 • PVC
tootttpuuytrgme t6,INNER'CASING OR TUBING 4,Mitrecustdosed-no .••, -`..
FROM To -DIAMETER I THICKNESS !MATERIAL • _
2.Well.CrinStn.iction Pci'Init a: . - - ft R. 14t-
IAsi a(l rlp,liroblc sr11 penal:J.(Lc.County;Saar,'•trariaare.friadoet eor,.l R
3;Wcil.0 (checkwel use): ' t7:Sr:Rh..EN .
Water'SDppiy Well; most.• . ?O -ntAdtell R IS COT St7,M: TRICKINESS. MATF.I1bAL
• DA1griuuittttal ClhfuniciptIiPttblic . 5 R. 15 ft. 1 . fa .010 SCH-90 Pvc .
DGeotl�Rnal(HeatingiCooling Supply} ®Residential Water Supply(single) ft. R in ' : I
nlndustrialiContniercial ' ©Rcsidknfal Water Sapp$(shard/ ttl (y0T To iaTeRtAL+:• EMPLACEMENT t fMilo sAMOU4T
. Dhligation - R.•
. . ft- .
.
'Rio-Water Supply Well ', RLMonitorip . . ' . ,•❑RccoYety ... `• -
' Injection:Well:- ft,. . ft,
Cr4QuifcrRccharge DGtottriiiwatcrRenicdiation -'L9.'SANu/CRAVEL PACK atgpitn.abtev' - .:: .,• _._-- - ... .
'FROaU.• '- ill' •.MATERIAL,• -EMPI.tI:Es5ENT llITHQn
QAiln(fcr-Storigc and Rccov-cty i7Salinity Ramer R.- It, .
i,
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ElAgmfcrTest C1Stomnsatcrfrainn fa ft.
17Rvpcti uetirTf Tcchnotog) (]Subsidence Control
r•10,'BRILLENGLOGIrittselt additioinalslicelsiinccccsartt ' '
DGeothenmt(Closed Loop) . DTrucer. ' FROM r To • ' DESCRIPTION(c+obr.hartlnctk a,t14nekfypr.i rain rite do.i'
mGeociienuat(}leatinrCooling-Retain? . DOtlter(explain under.#211 Reuultks) '1!.. ft.' {
12-18-23 TW-03• ft. - ••fL . - ! r '-'r"`y o j
.pate Weil(s)Coulpletefl: UVedl ID(+ ft. • . ft. • '' '''"'g;® �l t -f 3 .
Sa.1Yc11)iJlcat[nm: ft.-. ft,- • �. J/1 N ?.(�?d
Burress Residence - fur R: ""T •
FacfityklisturNaioc Facility ID#(Ifappli:ablcl R;- • ft,. - tli'a'�r►tq$.le �r..,
89 Rattlesnake Branch.Rd., :Canton, NC,. 28716 a;
I, . CiNC: .
• Physiea1Addiess.City.and Zip 2GREllttAt2K4' °
Haywood Temporary well; grab sample
Coattty Parcel Id:ntiticaupn No,(PIN)
5It.fi ittilude and 1Angittrde in degrees/mien tca/sccondsdr decimal(legrccs< 22.Ccrfifcat}ua:
(itnell field;oue b51o,ig isstdltekia} •
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N W . ' •14- r 4tiG► 12/18/23
Sigait,itsofCeiti Welt Contnctar• 1, , ' Dale
6.Es.(:tre)the walls): DPertnanene .or• ZITemporary • By signing this fanre,-1 frereby certify dull Mg Ire111.0 taws Mere)csm:nrrmd 8r,ac onh,nc-r•
iridt i5A Nat(02C.0(09 or 15A NCAC 02C..0200 Well Corrstr7acrtoa Starr ands and Am a
7.Cc.thix a repair to an esi`tingwell: IJYor or '111No cntir of Mir rrcorrd Ws(aten'pmrirrrd to dui owner.
. ff rh(s!s a iepolr,itli'oar knot,inveli coiw,ucvkoa.laformatlon and c410n(lie rurfare of the •
repair tmder#21 remarks araiau or o„the baCklif thin form. 23.Site diagr or additional well details: :
You twi inn g use the back of this page to provide additional well site details or.welt
8.lNuntherof sells constructed: 1 • - ' . . consttuctimt:detvils. Youiusy also all tclt:additionaipages if uecessary-
For nea,krtpk hr/ecrlart ar non-rarer inpphi n'rlts ONLY with the sautecausirurtioat,you ern
sa6mEronejarm. SUQt1EI1Ta1,INSTU TONS 1
9.Total welt depth below laud surface 15' • . .-(ft.) Sta. For Alf Wells. Submit this•fors•within 30 days of completion of well
Par mapakpfeircklslisr fill trrprhtifdif`ir i,,(armvpk-T€.'00•arul2@1f7O) con.i tenon toil,efollowing: I.
10.Static water level below top of rasing:• .(fp,) Division of Water Resources;Information Processing Unit,
ffirarerltwi is above costa;;ase"• 1617 Mail Service Cc nciir;Raleigh.,NC 2,769916 L7 •
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11,Borchotc diameter,2,257 •(in.) 21k For Gentian WON ONLY: i%faddition to sending the fomt to the address-in .
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24a above.also subtuit a copy of this Iona within:0 days of cptupletiot of%ell
12.Well construction method:DPT cousimction to the following: v '
(i.c.augni runty.cable.direct paste etc.}• ' { ' •
'if/it-Ilion of Water Resources,Underground Injection Control Program,
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FOR WATER SUPPLY WALLS ONLY: •1636 Mail Service Ceutc r;Raleigh,NC 271399.1636
t3 u Yield(gum) Method of test: lie.'For Water Snitjtl_y-:cc injection Wells:
Also submit one copy of this faint}vithitt 0,days ofcompletion.of
134.Disinfection type: Amount:
well conNIRIcaon to the county health department of the.couuiy.where '
constructed.
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FonuGtV-L NorthCatalinaDepot-tnrcntofEnvirotuunuatulNaturalResources-DivisionofWaterRr octets .Revised August 1tn13