GW1--00474_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD k0.1 Fat hvcriial Use plkiLlf:
This fonocaabc u_wd fat sin&in tutiltipk wells. •
I.Will COntractUr Information: •
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1 4011ATEWZONES • • • , • •
Rich Leraire . &DOM•. 10 DDSCRIPTION ..
Well Canted/plot'Nam
• ft.' 11- ,
2593A - .1 ! .. .
NC Well Contractor Certification Number f;Ifi•OUTER CASING(tOilitullratilfe-C11601t LINER Mali'ileobk)1.'. _
TO - DIAMETER! •• TRIMNESS : SIATETUAL
. Ir.. • ' . •SAEDACCO .
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te.-:INNERCASING.OR TUBING- '•":ibeimil er;A•ei1400pp-i.
FROM• TO DIAMETER, TRIMNESS 'MATERIAL ..---'
2.Well Constmtion liertnit-0.: - . . 0 'ft,, 5 ft;- 2 1 Ilk. SCH4 0 • PVC
lir'4 all opfilirable twit penriiAs(Le.,Couigy..Nicoe,Varicurce.flacepri.eta.) • .
in, -
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3.well Use(Clecelc WO'tie): • " " ; 11 SeltiliNi•-
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. . Vituli r , :TO - DIAMETHEI !I STOTSIT.E TIIICIODSS I MATIMIAL .
Water Simply Weil: . • . ... .
5 II. 1 10 . ft.. 2 ,! .010 SCH4 0 PVC
1.1Agrietdittral i ElMunidipal/Public•
ft.- 1 •• . .
EIGeothemtal(HeatingiCoolirig Supply) Clkcsidential Water Supply(single). ; 4" . i'I'.
OlndustrialiComntercial pllesidential Water Supply( red)
Shi • : :..FRosi - TO • MATE. RIAL - . EN.IPL.ACEME.riTMETTIOD AMOUNT
- -OkriCatirin • . . .
. 0 . ft. 3 - It. PORTLAND, • POURED
. Non-Watcr Supply'Well: . . • , . . . 1
. , ft: - - I . ' • . •
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•.. ft,
&Monitoring . _ . . IZIRecoyery, . . . • . . . .
-Injection Wen: - :R. ft. . . .
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ClArinifer.ReCharge • . IZIGiontidnuict Retnediation. . •19.'SAND/aRAVEL PACK lit aloilieAbtel,,
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, - ' " .FROM TO MATRIDAL• . EMPEATiEMENTMETHOn . .
. . r:ItIllIgigT;Stotage and Itecovtiy- . FiSalinity Bawler' .•. . 4 ' .ft. la II. SAND • #2
°Aquifer Test • . 1:1SiOnamtcr Drainnge:
' 'ft.-. . . •
13E1)0010101 Technology bSniAltienceConirot.' . .
it-ORtt,LING'LeGltillitiviidilitilinitl shiefi li 4i-cgs's:Int ' '
. LlqwEltennal(dosect Loop)• arnicer . . .FROM . •10 DESCRIPTION kolor.bantam iorrrock OK.vebi pIrc tle..1 .
CIGeotheitual(Heating)Cooling Retum) I:Other(eSplaht under#21 Retuatks) 0 'ft. 10 It. SANDY/SILT - •
. . - : 10- It.. ' ' IL ROCK , •' . ,„....,. .....„.„,„_, n;_,- • . •
.4:Date Well(s)CoMpleted: 1-2-2024 .'M,idi no#m1 •.. ' •--- . .
.54:Weil Locition: • .ft. It. 1 JAN 1 t3 2024 - .
McKENZIE REAL ESTATE . ft: ft. •, .
FactlnyosOWnerName • FacOity IDN Of appitable) •
-R.' .
516 $..Fayetteyi1le St. , ASHEBORO, MC, 27203 ft. ft, - .
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Ploijeal 441d0is-Cs);••nail Zip IL.IlEhl.SMK..ti . . . . .
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RANDOLPH. • . . , BENTONITE FROM 3 TO-4'.' . .
- Como). , . Nivel Ideolikation No.,MINI.,
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Sh,..fitittle'ailt1.1.(ingllittle,in dcgreigniittittOiSciand's En'decimal degrees: •22:Certification:. '
(duel)field,one lat)iong is. -sOfileioal) ,
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N • w • ------7'K.-1.1-1 OPPle44°N04. . 1/6/2024
• • •, , • - Signitilteeeeciti ._'411Contrzictrr ! • - Date •
6:Is(are)the well(s): ZPermancnt -or ElTemporary. tiy signing.this Ann;1 hereiq i•erfify thad,illeArglity)iyo.r Otrr!ll cursameed.hr.nty9rilrracr
Writ/M NCAC 02C.Otto or ISA NC4CiOIC.0209 Weil Conierariicur Stanclaids and rim a :
7.F.this a repair to en misting well: . ElYo or 181No rcliT of IN!recont haS mien p firWiti,.‘1 fa itAa writ thrner.
lit:tisk a repak fill Na balm wAII eausstuettattiufaiatafiou awl exptabi rUe mature ofrhe '. -• • I . -
:vizir(Order 021 remarks kaiari orr on the bad:of Mil.foriu. ,23.Site diagranior additional well details: •
You may.Use the bid:of this page to provide additional well site details or well
8:Nuntber of wells Constructed: 1 consttuction debits. You may also anach additional pages if necessmy. •
For mulapla kjeatou at pon,wiaer supply.welis ONLY With'dy same consfrialiou,you can '
sisfunit one prat: . - SUBMITTAL liTsISTE4TIONS: L .
0..Total Welt depth below land.SurfaCe; 10 (tp,) 24a. Pot.All Wens; Submit this fano within.30 days of coniptentiu Of Well
Poe nailapfe wells list all depths tcdttiyeur ism-rook-3@.2047'anti 20.3,1014 ' ..constiuction to thelorlowing7
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10. totie Water level below-kip of casino,: 6 111..) Division of-Water Resourees,information Pencessing-Unit,
elate,lad is abare casaux Ose"-i-" IGO Mail Service Center,Raleigh,NC-27699-1617
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11.Borehole diameter:8.25 (in.) .24b.For Iniectijot Wellq ONLY: In addition to sending the faint to the address in
24aabMe.also'sidithit•a copy-of this.form within 30'days of conviction of well
11.-Well enustroctionMethed: AUGER - COUSInteliOti to the following-.
(i.c.aager.ritzy.Cable.Meet FES1i.41} • * ,
. Division of Water Resources,Underground fujeetion Control Program,
FOR WATER SUPPLY WELLS'ONiLY: 1636 Mall Service Center.Raleigh,NC-216994636
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. .24e.For Water Supply&Injection WeRs: .
13a,yielth(gpm) . 'Method-of test:
Also submit ene cepy of this fatmlwlthitt 30 daySolcomPletion of.
1.31.4 Disinfeetion type: • Amount: well construction to the county health icicponment of die county.wherc•
• • constructed, .
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Fenn GW-I. North Carol Lea EX.--paanuentof Enviroorneitt aod'Manual Resources-Division of Water:Rcsouitm Revised August 10 LI
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