GW1--00475_Well Construction - GW1_20240116

q• WELL CONSTRUCTION REGO�r�� FortoternalIlsepNLY:
This farmconbc used Car singIeoni i1iipk wells \`K
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1.Weil Contractor Information: \
it41:-WATL•'R'ZONF.S'. .
Rich Lemire FROM TO DESCRIPTION -
Well CoringorName . ft.' ft..
•
2593A •
fr. ft. I , . .
NC•WcllConiractorCalif-toiiot:Nuii er • tS.'OUTER CASING(turnout-easediirRs)OR•LINERfifinp ticatik)-
• FROM TO DIAMETERi I T►nCK.N'F.SS• MATERIAL-
SAEDACCO .ft. . ft.. lio.
' Compa4 None :16:INNER'CASiNG'OR TURINGfgeatbertnal crosed4oajl):`_- `_ •
. -FROM TO DG.UE ER. • THICKNESS YIATEmAL
2.Well Construction Pet'iuit.#: . 0 R. 21' ft. 2" • 141. SCH-40 'PVC
Litt all applicable W Upinnits Iir.,County.Stare,Variative.(*at'at.trc) - .
R. ft: .la.' •
3.WcIR.Uso(dieeIWell ase): i7.SCREEN .
Water Supply Well . - - . - FROM. . TO .• .•ntAmEntn SLOT SIZE rittc}Csi is •MATERIAL
• C1Agrieultutal - ClhlunidipaliPttbliG 21 Ft, 31 R. 2" •ice' 010 SCH-40, PVC
OGeothetntal(11eatingjCooling Supply} , ©Residential Water Supply(single) R. 11.• ft. in •
•
•
.CllnduslriallConutiercinl ©Residential Wafer Supply(shared) -FROsR,°, TO. -- -NrATERIAL - • ENtPIACESIENTMETHOD£AMOUNT
DkTipation • • • . . ' 0 •• R: 14 • •ft, PORTLAND TREMMIE ,
Nog-Wage Suppl'Welt:_ . . • .
QDMonitoring pllcco%cry. ,, • R. ft •
Ittjectiou'Well: . . ' .ft.' ft. i .
•
OAquifcrRecharge OGioundiwttcrRenucdiation • 19 SAND1CRAVEL PACK lit aiiptn.abk)r -•
most •- TO ' 'AfATHRIAL:r. EMPLACEMENT MtSNOR
DAquifcr.Stortgeand Rccovcw []Salinity Hamer. 19 ft.- 31 ft. SAND #2 •
ClAquifcrTest. • DStomlw:Iter i)riinngc• ft. It..
DExp rimcntal Technology . OSldisidcncc CoMml =..' . . .
2a:DRILUNG'IAGIatiaclt:iidditiooatilicelsif nccessarti-l •
. OGeotiteinial(Closed Loop) OTEICer. FROM . TO . - DESCRIPTION f(ebr,hardneil,toillowdlynt:crain,l,e.dai
' - DGeotlteirual Bleat mllCaoline Return) OOdter(explain wider#21 Retnatks) 0 • :ft. .14 rt. ORANGE SILTY/CLAY
.
14 ft. 31 , ft. PIM •i' .
4.Date.Well(s)Completettc 12-22-2023 Well ID#M4I-2- •
ft: ft..
Sa WellLocation: ; 7— •f'" -"`
- PRESTIGE-FABRICATORS D, ft.
, Facility','Qirnet-Name . Facility IDki tit-appli able) JA N 1..6 2- 4
• 2206.Dumont St., ASHEBORO, NC, 27203 to ft. ;, `' X
• Pigsianl Addcass City.and Zip' '.21:RtlIIIARK$ ' - • 1.tVe !_;L y '
RANDOLPH BENTONITE FROM 14 TO 19'.
County Parcel identification No,(PIN)
$6.Latitude acid Longitude in•degrees/minutes/scedntls or dccirirai actives: 22.Ct .tificat1OU: - •• i
Of sett field,one atioaaitsufneicirg - '•
r' .
N `V. .
®. L.PJMI%�C-• 12/23/2023
SigtuuitaefCeni ._WeilCarmacter 'i7 Dale.
6.Is(are)the well(s):.f0Peinanent. or' LITemporar3' ity xlgrdnp this farm,I Irerebu certify that'rty Fe11 •)Her(urre)cvr�rrrucrerl air ac ordance
. with'I NCAC 02C.0100 or 1SA NCAC 02C,O200 hell Conitlitcrier Standards and that a
7-Ls this arepairtoan existing well; 17Ycs•' or 13INo :cuteofdttr word liasliOnproekled.toticllriltooter. '
if thfs'Is a repair;fill amAnoirie wit consulicriorthrjormartutr and explain to many of ale
repair[Order t21 rernaas,uctidn ar cvz the bailof tilt form. ... 23.Site Brame Ur adrlitionrtl well details:
You way use the back of this page to,;proviide additional well site details or welt
S.Number of wells constructed: 1 cottstruetime details. You inay also attach additional pages if necessary.
For Inalripte!leave'ar non-water.ritppl.i welts OJVLY ivlrh the same constructlat,you eon SUBhf[TTAL iNSTUC.TiONS
.whet'one form. - .. .. .
• 9.Total well depth below land sut'facer. 31 (ft.) Sta..Par All Wells:•Submit this fonn within 30 ikiss of coniptetion of well
For malriple weds'lisr all depths ifd(tivent(example,3@:00"aru1201ia0) ' Constntction to the foltotving;.
' 10.Static water level below top of casing:25' - - - ((I,) lib isipn of Water Resources;lnfttrmntion Processing Unit,
If tearer level is above casing;ay."+" 1617'RLai1 Service,Center,'Raleig NC 2769)1617
11,Borehole diameter 8.25"/4" . (M.) 246.For Iiilertion Wells ONLY: 1niaddition to sending the fort to the address in
24a aboi'e.also submit a copy of this fpntt within 30 days'of completion of well
12.Well consiettctionMethod:AUGER/AIR. _ constmttiott to the following:
(i.c:aa#t r.rotary,cubic dilet1Fitshetc.}. Division of Water Resources,UndeigroundInjectionControlProgram;
- - . FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccnth r.Raleigh,NC 27699-1636
I3a 'add tom) Mctlmd of test: 24c.For Water Supply&Injection Wells:
Also'submit one copy'of'this fora:-Within 30 days ofcompletionof
13b.Disinfection tvype: Amount: . . tvcli constnutinn to the county hcalUi department of the.county.wirem
. - contacted.
Fonts GW-t North Carolina Depaament.of Eovirantueiii and Natural Resources-Division of Water Rma.rat Revised August:11 E3