GW1--01327_Well Construction - GW1_20240304

1
WELL CONSTRUCTION•RECORD Fig IntcrnalttscMY:
This form canbc'uscd for single Or multipk walls'
1.Well Contractor Information:
ti:WATER ZONES i
Tyler Brown . . . FROM ' 10 DESCRIPTION
Well CorA Mellor Nanrc R. R,.
•
4625A .ft. . ft.
NC Wd Contracibrecnif[ention Nuttier. 15..OUTER CASiNG(foe tnnttl=rised:a'c(Is1'OR LINER Wait RCabkl•,
FROM TO DIAMETER THICKNESS. MATERIAL
SAEDACCO 0 ft, 19.5 It, 2 la,.1 SCB-40 . - PVC
Cnntimuy Name t6..INNER CASiN G OR-TUBING .thermal dosed-lot'
'FROM TO•• DIAMETER THICKNESS MATERGL
2,Well Construction Penult It: - - ft, ' . ft. "in. .
Ilsl all aryallc aNe urlpeintits An.County.State;'-Vnrinacr,fle ae ere_1'
R, ft .to '
• 3.Welt.Use(cheekwelluse):' • e7.SCRIEN •
' Water Supply Well: FROM'. . TO 'nttrnEn:R SLOT SUE, THICKNESS i MATERRIat.
DAgtieultural CIMunicipaltPttblic 19.5ft, 34.5 ft. 2 ice' 010 SCB-40 PVC.
DGeothettnal(tieatingtooling Supply) I:Residentiat Water Supply(single) ft ft. in b
©ludustrial/Coninlacial OResidcntiat Water Supply(stated) • -ts:GROtrr .. - II ,
FR05I TO. . .MATERIAL • EMPI ACEMMTSIETHOD 4AMOUNT
. ' ❑ir'iination. . . , 0 ft. .13 It. Bentonite c iAeattie
'Nou-Water Supply Well:: . . . .
EIMonitoring . . ORccoycip
InJecilon.WCll:- . . . . . ft,. ft. •
O'AgnifcrRecharge OGtoondwaicr Rcnicdiation- • 'e9:'SAND1GttAVE1?PACR(if agydlcab[cl
'FROM • TO' •MATERIAL. : E\ipi.AcEmt•:NTMt:ruon '
IIAgniter.Storargc and RccoF•ety IJSalinity Bari-ice 17.5 ft.: 35 ft,. Gravel pack #2 • •
❑AgtiifcrTest 12Slarimmtctilrtina&' ft. It. •
OE:xperimcntal Technology g5Rbsidcnce Control - • • •
-
2n.'DRILUNG'LOG(attach-additional sliceta if ncccssan•I
OGrwlhennal(ClosedLoop) OTracer FRONT• TO DESCRIPTION(cube.ba e.+,wRw,crinnc:;a 4,e.nisi
DGeodreaual(FleatiiilCoolluaReturn) . OOtlter(explain under#2tRetualts) ft. • ft. 1
ft.. �f • i
4.Date Well(s)Conlpleeteil: 2-14-24 Well iDtIMI4-4
Sa Well Grcatinui ft ft,:. j " x'—. L d)\! P
Kayser Roth ' ft, t. '
n 20--4
FacilitylOiencr2Januc Facility Ipy Ofappii able) ". ft. •ft •
- hn A. �'
714 I-40, Graham; NC,.27253 .ft. • . . ft, i In Ovine ten rprC,.., A
PlnsiealAddioss.City.andZip• 'It:Rk:14IARK3' D C. "
R
Alamance • . _ Bentonite seal 13'-17.5' ,
Canty Parcel Idanti1icalionNo.(PIN) i
Sli.)altitude and L.4ngittnie in degrces/minuteslsecrindsor dccintal cicgrecs
3 C tllt2. isaion:men field,one latilorgis sufficicia)' i ,
N e 2/15/2024• Sigmcitld Weal ac 6.is.(are)the u•ell(s):.ZIPeemanent. or DTemporary •
Hy rigarng whir jorm;'1 lrereLy cerrijy that tbr,irrll{s1 wax(Kura)cwrutrurfrd la:axxonlmice.
iiith 15A NCAC 02C.0100 or-1 SA NCAC 02C.0200 Well ll Construction Swirlards and-kat a •
7.Is this a repair to an csi'ting uell: i7Ycr•' or ONo c.7iy of Mk record ha been provided to grained corner.
If thfs'is n rrprlr,fill oat laroirwwell carutnrrtlnradu/omurrloa and explain the mare of the
repair Linder021 icmarks arciion nh on the bocL of this form. 23.Site diatgram or additional well details'
You may rise'tie Bach of this page to ptoside additional we,site details''Or well •
8.Number of wells constnicted: 1 constmcdolidetails, You may also attach additional pages if necessary-
For nrtaltlplc hfecilaa or rain-outer supply wells ONLY with rho sameconstrucriai,you can
submitoar form: SUDMLTTAL iNSTUCTiONS- '
9.Total wellileptil below Laid surface: 35 (ft,) 24a. For All Wells: Submit this fault within 30 days of*completion of:yell
For nudrlple wills list off depan ffdlt[gust(cxarrtpfe-MIN'anti 20100) conSlroction to dm following: • I. • . -
I
10.Static water level below top of casing: - (f- .) • Division of Water Resources,Information processing Quit,
theater level is above casftnF;Gate"+" 1617 Mai[Scr•vicc Center'Raleigh,NC 276994617
11,Borehole diairictcr,67 . '(in.) tab.For Infection WeIIq ONLY: in addition to sending the form to the address-in
.24aabose.also.submit a copy of this form within 30 days of completion of well
Rota—sonic constmetioii to the followut F
12.Rellebnsfrltction method: g
(i.c.auger.'rotary,cablu�direct gash-etc.) 1• -
•. Division of Water Resources;Uuder'w ound Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
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131 Yield(pm) 2•tc.-ForWatcr Supply&Injection Wells:I
\lethod of test:
Also'.sutra*one copy of this feint•withitt 30 days ofcompletion.of
13b.Disinfection 0---per Amount: well constmction to the county health iepanment or tbe.count_v.whetc
• consintcled.
Fans GW.1 North Corollas.EA„pmunenl of Emirotancm and Vanua]Resources—,Division of WaterReratr Revised Atgust2613