GW1--01333_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD For[Kemal Use-ONLY; •
This form can b:used foi single or nlultipk wells• -
1.Wt•L1.Contntctor Information:
...NI.WATER GON ES
Tyler Brown FROM TO Or CRIPTIOY I
Well Contractor Name It.. ft.
4625A ft. ft.
NC Well Contractor Celt ificatioii Nmilicr ,'.IS.OUTER CASING(for multi-cased wells)OR-LINER([f ap Beetle).
FRONT TO DIAMETER*r THICKNF..SS• MATERIAL
SAEDACCO 0 fG 18.5 IL 2 id. SCR-40 PVC
Company MOM" t6.'INNERCASINGOR TUBING_(geothermal ctaccd-Ioap),
FROM TO DIAMETER. THICKNESS MATERIAL
2.SWII Construction Permit#: R. R, �.
lit ail applic aRe is!t permits-(Lc.County.Slate;.Variance,fryg6al etr,J -.
-
.ft. ft ,ip.
• 3.Well:Use(check well use): IT-SCREEN
Water Supply Well: &trOM. . TO DW.AMETI:R MOT SI E THICKNESS I MATE(UM.
18.5ft. 39.5-ft. 2 IlL ',.010 SCH-40 PVC
CiAgtirulntnal ONItinicipaUPublic 4
Cl mt Geotheal(Heating,'Cooting Supply) ®Residential Water Supply(single) R. ft. in.
Clladustria fConmten ial ©Residential Water Supply(shared) FRo OUT TO M TERIAL CdtPIACEMENT\IL"f110D&AMOUNT '
Obligation 0 ft. 12.5 ft. Bentonite c 'e
Mitt-WaterSuppl}'Wcll:
R. R.
ItlMonitoring . DRecovcty ..
Injection Well fG ft. •
ID Aquifer Recharge DGioundwalcr Reniediation t9.SAND!GKLtVEL•PACK(if appucahtel"
I+ROSI To MATRRIA I. - RSIPLACK'.INTMITIt0n
❑Agntfer.Storage and Recovery IJSalinity Harrier 16.5 R. 39 ft. Gravel pack #2
l]AquiferTest ❑Storm atcrDnina ft. • ft..
•
17Experiniental Tmlinology ❑Subsidence Cordrol
30.DRILLING LOG(attach additional sheets-if acccssan•I
DGeothennal(Closed Loop) DTricer FROM . TO DESCRIPTION teobr.iutrci,urE'ni klrtx.;rainvre,crtt'
OGeotltenttal(Heating/Cooling Return) IJOther(ecplai(t under#21 Rettiarl si ' :ft. ft.
It. ft.
4.Date Wells)Cotrlpletetl: 2-15-24 Well ID#MW-9 -
ft. ft. _
5a.Well Location: fL f4 '"k t.�".- L. L Li
Kayser Roth ft, ft.
Facffit)','OicnerNm ue Facility lD,e(ifappG.ablc) I - -ft, _ R, NEi'r so 2024
•
714 I-40, Graham, NC, 27253 7
.ft. ft. tt1;C;7(lo:t�1: r^. asK t1t d
PlrysiealAddressCity.andZip" ;it.RIMARKS +iQlf3G
Alamance Bentonite seal 12.5r-16.5r
County Parcel Mollification No,(PIN) 1 -
ib.Linitude and Lonlitnde in degrecslmirtutcslsccnnds or dceirDal degrees: 22.Certification:
(ifocn field,One l;W'loim iR$uI11cku1) '
N W nrtu / 5 r � 2/15/2024
Sig afCcitifiedWellContractor Dale
6.Is(are)the well(s): %IPenrtartent- or (Temporary Ily signing thir fain;'!Irtrebr certify that she(cell{sl vats(urn)cvriaiructcd br accordance
irih 15A NGAC 02C,010.9 or 15A NGAG 02C.0200 Well Coastawr(Ott Sraiutards and Mai a
7.Is this a repair to an existing well: 0Yes or ElNo re7iroffhit word brs beta provided Al OM itrll rnrn(r,
!f this fs a iepah.;fill oar kroirn well coartatctlaa brformarbti am!a nplaht the nature of the
rep air:o der921 reaurrks Section ar cur the bark of fhb-form. 23.Site diagram or additional well details:
You ma):use the back of this page to provide additional well site details or.well
8.Nunther of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple ialeellon or eon-rarer ripply trills ONLY with rhr sortie coastrurtiotr,you on
subunit one fmm. ' SUIIhIITTAL.INSTUCTTONS '
9.Total well depth below land surface: 39 (fc.) 24a, For All Wells: Submit this-loon within-30 days of completion of well
For mahlple wels list oil depths(/dlp'i'ent(cxaarp(e-3@200'atu(2@ 1110) construction to(Ire following:
1
10.Static water level below top of easing: (ft) Dit•ixinn of Water Resaurres,Information Processing Unit,
!f crater level is alcove cvs(ag.use"+" 1617 Mail Scr ilce Center,Raleigh,NC 27699-L617,
IL Borehole diameter.6" (In.) • 24b.Far Gelation Wellq ONLY: In'addition to sending the form to the address in
24a above, also submit a copy of this fonm within 30 days of completion of well
12.Well construction method:Roto-sonic - construction to the following'
(le:auger.rotary.baby direct posit-M., •
'Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Centcr,.Raleigh.NC 27699.1636
s
f3:0.Yield(]!pot) Methodof test: 24e.door Water Supply&Injection{Vel1s:
Also submit one copy of this feint Within 30 days of completion of
13h.Disinfection type: Amount: well construction to the county ltcaltl department of(tic.counh`.where
i
constructed.
Form GW-t Noah Carolina I)cpartrueru of Euvirarurrru aid Natural Resources-Division of Waier Rreeoitoes Ririscd August 3*O(3