GW1--01326_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD FoTthrernnlUs'ONLY;
This Earthen be used for-single Or tnultipk wells. ,
I.Wcll.Cuntrletnr Information:
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Tyler Brown FROM TO
O . DESCRIPTION ' 1
Welt Conitaetor Nanie R, It, .
4625A . . rt. ft.
NC Will CantractorCertiftctienNmitrcr - :IS.OUTER CASING tfoemulli-cesedirensF OR-LINER(if3p'ticabte}..
FROM TO I DIAMETER,' TitIC'KNESS• MATERIAL
SAEDACCO 0 ft, 10 R. 2 hi. SCE-40 • PVC •
Contptuty t�anle DINNER CASING OR TUBING(crotherntal chased-tohp,:_ '
O-FROSI TO_ - ' DIAMETER. THICKNESS MATERIAL
2.Welt Cot'itruclioa Perltiit fir *ft, . ft, 'in.
• Lis'r oll applicable urll pennits,(Lo.County.State;.b 1i idea.fr.yen rn r1C.l. . . .R. ft. lit. ,
3. elt.Usc� (chccl,Well DSO,: CI:SCRS.EN_
Water Supply Well; FRosr. To DDTA tETER storms. TIICKNIISS I MATERIAL
17Agnie»itutal . • ClMttnicipaliPublic . 10 ft. 25 R, 2 in !.010 SCB-40 PVC
ft. f. : .in, '
®Geother al(HeatinglCooling Supply) I:Residential Water Supply(single) I. .
®ilidusirialiCounniercial i lResidential Water StiPpl)'(shared) '-FeoGRm.OUr •TO MATERIAL... ... ES[L'LACE IEVSNETROD RAHOnNr
Dltrigatian . 0 • It, 4 fL Bentonite c
Non-Water Supply;Well:' . I . .
R1Monitoring . • .pfeeoycry R.`. fL
. Inject(on.Well: . . h, , ft. •
DATtoifer Recharge t ll.;roundi atcr Rcntedialion -tv:'SAND1GILtVEL.•l ACK(if alytlicabtel .. . •
• 'FROST- ' TO SAAXitRIAL .. -- P.5IPLtetsreNTSlr:Ttion . -
f7Ai[nifcr.Storagc and itccovciy flSalinity Harrier 8 ft. 16 ft, Gravel pack #2 -
❑Agriifcr Test•. QStonmMiter fmiiia ft. • ft..
❑Experimental Technology ❑Subsidence Contort - .. .. . . •.
• 20:DRILL.IING'LOG'fallach additional sheets"if reeccsmni
OGeotltcnnal(Closed Loop) . OTricer. .FROST TO DESCRIPTION ceobr.Imednevt,virl'rnrktrPt-gee*site.(Ira
OGeotiteitnal tHeating+Cooline Return} •OOthertexplaih udder 4211 Retinas) :fL ,fL ,
ft, . ft. i.
•t.Date�`r@ll(s)Coplpletcd: 2-23-24 Well iD#MW-2 ' . •
fL ft_
5a.Well Location _
ft. , - .,-, .r.
Kayser Roth R ft• , A i�'4✓
Facility,0irncrNimie Facility ID,: ifappli:ablc) R, ft. n
714 I-40, Graham, NC; 27253 MA 0 [ ,n,�
R. ft.. . I
.Ptgsioal Address.City.and Zip• 21:REMARIC.4 , tTli-ofic.a:tr it ?rc;. e t..ht I
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Alamance Bentonite seal 4'—8' . I DWQi 3L •
County I"arce7 Itic,diticatipu Ni,(PIN)
Sh.-LadtiitteMid C.c ngitadc in ilcgrccslminuieslsccondsor decimal dt•gtecs. 22,CcitifitatiDn:. I
(tlrrell field,one latrlona is snflickid) . i
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N . W 5i 2/15/2024
Signitur:ofCcrtified*ell contractor • Dale . ' .
6.Is(are)the[yell($}: $IPt.nnanettt. .or [e-mail] .By signing thu.fum.1lreroby certify dug,At irtlifs)was{rump tv,ulNCICd in rtreo fiance
'frith 1M NCAC 02C,01011 or 1 SA NCrlC 02C.0200 W411 Constrie.'ttwr Standards mid that a
7.Ls this a repair to an existiag well: £IYes or Nilo 'royir of Mir riverdltax#ic.mprnakd ro;ly;kill,rf ener.
If 014'1s a rt yarr;fi out dttoftii weld raagarcrlon-larforrrurrhin aml rxplaln rbe aarare of rlte '
repair tinder 22i icmarki.tirciiaii o'r cot the had of rids form. 23.Site diagram or additional will derails:
You nnay use the.back of this page CO,pir ide additional well site detail's or.well
S.Number of-wells constructed: 1 Construction details. You•May also atiae(taiididonal pages if nccesriry.
For nridtlple i lecilon or oral-parer snpplr-wilds ONLY mirh the maceausrruerlon,sets eon
su&mltone for, SUBNIITTAL NSTUCTIONS
• 9.Total welt depth below laud surfacer 26 (to -2-0a. Fur Ali Wells; Submit this rani;Within 30 days of completion of well •
For matrtpleweds/isr all ileplitrIfdi�'ivciu(c.rmttplc-3'20.11'awl 2caMa) construction to thefoltaning; • i ;I.
10.Static Static water level below top of casing: Or.) UiviSinn of Water Resources,Information Processing Unit,
if ream'level dv alive mail;ease"+" - - 1617 Mail Service Center,Raleiggli NC 27699-1617 •
IL Borehole diameter:6.. . -(in.) 2Ab.Fur Infection Weill ONLY: in addition to sending the form to the address-in
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2-la above.also submit a copy of this:form within 30 days of conipletinli of well
• 12.Well ceustrnction method:Roto-sonic cotnsimctiott to the following:'
(Le.auger:ninny.cable.direct Mish.etc.} !
Dirisiou of Water Resources,Underground Iirjecaou CourraC Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center Raleigh,NC 27699.1636 •
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t3a4.Vidal Wm) \Ictira[I'of test: 2dc.-ForWatcr Supply&Incettou Wells:
• Also submit one copy of this form within 50.days ofcompletionof
13h.Disinfection type: • Amount: well construction to the chanty health'department of the.Crnmty.nhcm
constructed.
Feint GW-I Rosh Catalina Departntcnl of Envirarutrnu and Natural Resources—Disiiioa of Wale Etecotroes Revised August-11113