GW1--01366_Well Construction - GW1_20240304

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WELL CONSTRUCTION'RECORD For ltwcrnal Use ONLY:
This form can Ls:used far singlet::multiple wells•
t.Well Contractor Iufoma' lion:
4.WATER ZONES-. I .
Scott Hunt, Jr FROM 'rt)' NA/mpg/NI
Well Cora-actor Name 32 ft. 37 ft, black compacted sandy silty
4561-A . ft. fL t I
NC Well CotdmcterCcitiflcatiaoNJuiite: a5.`OUTER'CASING ink-mall i-rrsedircthlOR•LiNER(ifnn ficsIkl
. FROM III DIAMETER THICKNESS MATERiAL
SAEDACCO ' ft, IL ;II.
111 ,,
Company Name 16.IN.NF.R CASING OR TUBING(teatlurmil dosed-loop)..•
-PROS] lfo DIAMETER. THICKNESS MATERIAL .
2.Weil Construction Permit#: . . ft. r ft.T ;in. .
ListallGpphcabk vrll permits,(ir.County.Stati!.-.Varianre.Jr tial etc,.)' .
R. ft... nt,
•
3.Wilt Use(chcele.Wel�use):• 17:SC:RI:EN
=Water Supply Vell: • ERusi. TO . DIAMETER 1 SLOT mix TIItc1NISS 1 MATERAAt, .
❑Agricultuwal - oMttnicipal/Pobiic 32- ft. 37 ft. 2 •lib .Ol sch 40 " stainless
®Geotheiinal(Heatngit ooiing Supply) I:Residential Water Supply(single) - fL . ft. in.
El Industrial/Commercial , DResidential Water Supply(slotted) FRO I Q lirr TO . MATEFHAL l\IPLICESI iT METHOD...4 AVOnNT
❑krl ration - . . ft. ". ft.
Non-Water Supply Well: "
- - R.
®Monitoring O p•Recosr '
-Injection Well: • IL- .ft.
•DAnnifer Recharge . O 3irnundwaicr Rcnicdiatinn -19.SANDIGHAVEL PACK(if applicable]' .
•VI4OSI' TO - MATtottvi. • • RUPJa%C'F:WNT SD:01011
DAiinifer-Stotagc and Rccovcty ElSalinity Hairier . - R, - MI i
•
17 Aquifer Test- 'f3Siotnnlatcr Chain*.
•
• ft. I B.
• f]>?gJcrimcntal Tochnotog 1751drsidctkc Control -20.DRiLLiNG-LOG(attach additional sheds-lfnccessarvl -
❑GoothertJsal(Closed Loop) l]Ttacer, . .FROM TO _ • DESCRIPTION(obi'.hnntner.wn'na:kOpt.Mill ucade)
lGeeodieitual(Ileating/Coolina Return) . ❑Outer(expiain under#21 Retuatis) 0 _R. 3 ft. gravel
3 it,. 12• ' ft, sandy silt -
d.Date Well(s)Completed:•1-30-24 .Well mg SB-4 •
12 ft. 20 ft, sandy cobble layer
5i.Well Location: 20 ft. 37 AL black compacted silty sand
Pactiv Evergreen Canton Mill • f4 ft.
FaeaityMiusr Nanse _ Facility IDa(ifapp6:able) - R, - ft.
173 Champion Drive, Canton, NC, 28716 . . R. rt, ' . •
Pln3icalAddiass.City.and Zlp• -21:REaLAI{Kfi-
Haywood •
- _drop stainless steel screen to get water -
Comity 1!arcol bknlifc1mon No,(P1N) sample • ,
Sb.L.atitirdc amid I.ongitude in degrees/minutes/secriaids or decimal dccrccs: 22.Ccrdtle:Wi n:.
(Ifsiolt field,one tat/longIg SufliCkrn) - 1' •77;:. .••..+,
• r �` �£"`
N , �Y 1�� i� 1-)2/4/2024
Sigcm .,;xt Cci1 ,. %Veil ContrxtMA N'1 0
n A 2024 Date
6.Is(are)the well(s): ❑Fennanent or BtTclnporal}'
il}-aigubrg Jlrir juror;1'1'rereb}•certify dial the el!{s•1 way(were)cx»irJrucled Lc mcrattlmcx•
frith 1511 NC11C 02C.0100 155, i 4 sC.- ,9 I' onsirflii Jr Standards and that a -
(p'l+a7ci 01', +a tJ#tti
7.Is this a 1xpalrl'u ail custingncll: rJY�w or I9Nu ce�riritjthis rtcnrd has6,ierr primuii• ro i f���l�t,1i.�'a�
((this'lsorepair,fill oat Cr,oiritwddco ltuctloa'lufarmrrlonwithr.cnlalntlirtortureofthe ',i�'r!OG
repair raider#21 femme i,irct av or on the beak of this fame - 23.Site dhagram or additional well deltdts:
-You may use the back of this page to•provide additional well site details or well
IL Number of wells ce istrticted: 1 - constmcdon details. You may also attach additional pages if necessity.
For rultipie bdectlon at awl-Jrarer suppl;•wells ONLY with the store corrsrruEtlat,;two can
.sahmir'anc-form. ' SIUBMiTTAL iNSTUCTIONS
I
9.Total well depth below land surface; 37 (ft.) •24a. For All Wells:. Submit this'faro within,30 days of completion of well
-For ratihiple writs lis,aft depths ifdi4li•renr(example-3Q200'and 2es WO) • construction to dm foitoning; I 1 - • "
10.Static water level below top of easing: 12 (ly,) Di1'ibis of Water Resources,Information Ptucesming Unit,
if muter lee!Is above casing;we"+" 1G17 Mail Service Center',Raleigh,NC 27699-1617
ILBorehole diameter:6„ - • -(in v
.) 2db.For torment;WellONLY: in addition to sending the form to the address in
24a above,also submit a copy of this faun within 30 days of completion_of well
12.Well construction method:sonic - constmetilnt to the following:
(ic:auger,rotary.table.direct push etc.) •Division of Water Resources;Underground Injection-Control Programs;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
is
13a Yield(gym) Method of test:_ 24e,'For•Watcr Supply&Injection Wells:
Also subtimit one copy'of this ferns iw•itbin 30 days ofconlplelionof
131t.Disinfection type:_ Amount: will constmction to the county health depanment of the.coltnty.where
constricted.
Fan'GW-1 North Carolina Dcpanntent of Eneironnri l ansi Natwal Resources-Division of Water RecoLrc s , Revised Acgust10l3