GW1--01365_Well Construction - GW1_20240304

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WELL CONS RUCTION'RECORD' For[Mental Use ONLY:. I
This form con be used for single or multiple wells
1.Well Contractor Information: '
14:tiVATLR ZONIS I^
Scott Hunt, Jr -. FROM • 'ft) ' - 'DKSCRIPr1ONI -
' WellCoranxtotNante 27 ft.. 32 ft, black compacted sandy silty
4561-A ft. fr.
NC Weil CantmnorCanification NwiL+ei 15,OUTER CASING[fur-milli=elaseteUi tii)`ORLLiNER(VIM llicabkY
mom m ntAMETKR+ THICKNESS MATERIAL
•
SAEDACCO • .ft.• ft- 'hi.
Company Name 16.1NNER CASING OR TUBING(gs thermal eloscddoop)
- . :FROM - TO DIAMETERS TICKNESS MATERIAL
2.Well Construction Perfitt q: . . . 'it: rt, ,hi-
1 rst eV applicable seen permits-(Li.County;State,Variance,forerb etr..J ft; It. M.
3.Welt Use(chtckwell use):• '17.SCREEN
Water Supply Well:-�.. - _ r FROM TO 'DIAMETER SLOT SIZE THICK NINS , AIATERIM•
• ❑Agrnculttt[al ❑Municipal/Plibhic' 27 ft. 32 ft. 2 iri Ol SCH 40 stainless steel
10eothcmnl(Hcatingi'CoolingSupply) ❑Residential Water Supply(single) - ' -R' ft. in
©lndustriallConmicncial ' .'©Residential Water Supply(shared) -1yR8";0611UUr'To- '1'.WRtM. • EMPLACEMENT METHOD s AMOUNT
• - ❑lttipntion -. . .ft. ' ' ft.
Non-Water;Supply Well: .
• ft. rt.
ra.Monitortng 17ltccosery •
Injection Well: . - .rt. rt. . . . . . •
- C]AquiferRceliarge" ' ❑t`ioundn:itcrReatediation --19.SA.ND/GRAVELP,ACIC(if uPPucsbtcl°' - - -
' roof- ' 10' . 1 MATERIAL KMPLACEMENT\MF:7110D
0Aiinwfer-Storagc and Reeovcty 17Salinity Harrier • , ft.. ft.
❑Agtiifci Test 175iommatcr Drainage•• • fr. iL
Al?opc[iprcntgl Technology. ❑5ubsidcrrcc COMM: • :la:DRILLING LOG(attach additional,hcelsIf oecessan't
•
❑Geotltennal(Closed Loop) ❑Tracer. • .FRO1r' -to • DESCRIPTION feobr.hyMncs9.aanickiur.miniwre.dal
• ❑G:odic:mai(Rea lm:CCooline Return) •❑Oilier(espial);under A21 Renialksl 0 rt. 3 rt.. gravel •
_
3 ft. 12 ft, sandy silt . •
..Date Wells)Cbngdetcd:'1-29-24 Well ID!!SB-5 . .
12 ft. 20 ft, sandy cobble layer
5a.Well Location:1tion: 20 ft. 32 f,- black compacted silty sand
Pactiv Evergreen Canton Mill ft. ft, - .
FacilitOisri,rNmac. Facility lDk(ifappliaable) •
ft. ft.
173 Champion Drive, Canton, NC, 28716 ft. • ft,•
Plii•sicnlAddcss.City.and zip"• '2I. tA R1:aRK.S . -
Haywood drop stainless steel screen to get water•
Com*: 1?orcc3 ldenlifreol[on-Nu,(P1N) sample j '
Sb.1.-Mitiidc acid Longitude in dcgnces/minutcslsecnnds or decimal ttogrees: 22.Certification: r � `
(If eiell field,one jaltlotig if stall:k W) �+
• I.
• N. • w � /._:.y - MAE 0.2QZ4 2/4/2024
' SI@esi z_Ccn.ti y Well Cenleictar - �Doe
6.Is(arc)the tt'ell(s):.❑PClntatlenl .or zlTemporiny •Hy signing des farm 1lrerrby ce t;.p'il1oiVa:( ;i •
�} clGT. k�' {wt
Kam-turfed bt,errordanre'
War 1 M NCAC 02C.WOO or 15A NCAC 02 4-IRICelat Standards and:be:a '
7.Is this a rei:airto Lin existingwell: 17Yes or llANo o-pyofthk record has heen proriN,ed ramie r!'serer.
lfthfs'is o repatr,fill oat Rroiii led!estain cPoa brformar'wt and crploln ncC,Newre of rhr
repair a der021 rcnurrksirciiart oral the bark of thts form. - 23.Site•dIagram or adtlitional well details: .
• You may use the back of this page to provide additional well site details or Well
8.Nmuberof wells constructed: 1 - - construction details, You may also attach additional pages if necessary.
For ivalrink 1rt(ecil0.1i or ooii-irvrer sappJ,v writs ONLY with"nct.sine ctnrs(rurtloar,pa csit
sahmirenefarm. ' SUBbMITTAL IN. SI 1TCTiO.NS.
9.Total well depth below land surface 32 (ft.) 24a. Fur All Wells: Submit this fora within 30 days a_f completion of well
' For ntuldpk'icdk list al depths ifdiRi+re',u(caantpfe•3@:(10'oa(201001 ' constnrction to the following: I -
10.Static water level below top of easing: 12 • • (ft) Division of Water Resources,Intertn:ttion Processing Unit,
- If water.level Is above cgsfrrn;ease"+" I617 Mail Service Center,Raleigh,NC 27699-1617
11.Bor elatte diameter;6" (im) tab.For infection Wi tlq ONLY: in addition to sending the foul to the address in
24a above,also.submit a copy of this ffoitu within 30 days of completion of well
12.Well constiuctiouiuethod: sonic consttuellon to the follo'vhtg:
(i.e.auger.rotary,Cable,dime"push etc.} Division of Water Resources,Underoronnd Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Cente!Raleigh,NC 27699.1636
13a Yidd(pm) Method'of test: �4c.For Water SumPIv Se infectfan WcilIs:
Also submit one copy of this font wttbin 330 days of completion.of
13h.Disinfection typer - Amount: wctl construction to the county health department of the connly.wbcre
constricted.
Farm GW-t North Carolina Department of Environment and Natural Retourees-Division of Waiet Rmatrces •.Revised Ate 2*13 '