GW1--01372_Well Construction - GW1_20240304

i
WELL CONSTRUC'1'[ON RECORD Fur Ite:tat Use()KV: '
This form can be used for siarle er nulnpk wells
1.Welt Contractor Information: '
•
`1.1:WATER ZONES ' .
Scott Hunt, Jr FROM TO •DESCRIPIII)N
Well Contractor Name 30 ft. 34 ft, black compacted sandy silty
•
4561-A R. ft.
NC Well Contractor Certification Nadler
OUTER CASING(fnr'mntlt-caved ireRsl OR LINER i nit tncuhle),
FnoAt I TO DIAMETER 111ICKNENS MATTRIAL
SAEDACCO rt. it. ln.
Company Kum UG,INNER CASING OR TUBING(geothermal closed4(oup)
. •FROM TO DLAMETER_. THICKNESS MATERIAL2.Welt Construction Permit#: 0 R: 24 • ft. R2 ill!. SCH-40 PVC
list all apymlirnblr,tse11 ponoih(hr.Cate',Smamr,V iriarxr.frialieil are.) •n. ft. in,
3.Well Use(check well use): t7:SCREEN
- - - FR `ttL TO .•DIMETrK SLOTSI?A IIIIC1tNENS. NIA',TRIAL
2Water SupUp ply Well: }
34 • 11. 2 im Al' SCH 40 1 PVC
DAglicultuml 1fhfunicipal1Public 1111
DGeothemtal(Heatingltooli ng Supply) ®Residential Water Supply(single) R. ft. in.
D ludustrial/Conmlcrcial ©Residential Water Supply(shared) .la:GROUT
105r TO. •MATERLAL I EMPLlCENIENT METHOD&AMOUNT
10 irrigation 0 D.. 19 ft. portland I trimniy
Non-WaterSttppl,Well: ft.®Monitoring DRccosciy - ,
Injection Well: - - R• ft.
0AtluifcrRectlarge DGrouridwaicrRcntcdialian ,t9.SANb1GI1AVEL PACK(lfatrplleablet•
FROM TO ,MMA•rRRtu, PAIN ACt:RENTMtntan
DAgoifcr-Stortgc and Rccovety DSalinity Harriet' 22 ft.. 34 fl, sand number 2
El Aquifer Test Dm StomatcrDrainage ft. ft.. -
❑kiperinienlal Technology DSttbsidcttcc Control • .
An.DR!LL1NGLOG(attach edit Mortal w6cNiif acccssan•1
DGeotkemml(Clusetd Loop) l7Tnicer- FROM• to DESCRIPTION itobr.hnRfic.+.L.W me t%rm.min we.dta
DGeothenuat(Heating?Cooliue Return) DOther(explain under##21 Remarks) 0 ft. 3 rl gravel
• 3 ft. 12 ft. gray silty sand
-1.Date Well(s)Completed: 2-6-24 Well mil ow-4 12 IL 20 fL sandy cobble layer
5:1.Well LOcatEnn: 20 ft,' 34 ft, black compacted silty sand
Pactiv Evergreen Canton Mill ft. 35 ft, bed rock •
Facilit)lOicoerNante Facility ION(ifapplieablc) 'ft. -- -II, - - --- - - - - - -
173 Champion Dr., Canton, NC, 28716 R. It. ,
Physical Address_City.and Zip• .21.REa1ARK.S
Haywood 3' of bentonite seal from 19-22'
County Parcel lt1enlifictllionNo• ,(PIN) �-- ^.;^-a .0,.,
Sb.L.atitudc acid Longitude in'degrees/minutes/seconds or decimal degrees; `�"�' '� d--d..6
(ifu''ull kid,one Iatrloug is stdllckal} 22.CetTifraHon:
,oMAr�; 0 20Z4
r- W ljiW-•" 2/4/2024
Stgrat e.aCcnsi:t Well c'AQLrlrtf teen Prr r2 57,S Dale
1.j 118$
6.Is(are)the tvell(s)r 10Pennaiient or EITemporat}'
By sibling this farm,1 hereby terrify th tD1431.. c•'1A,0Gis.(I:rn)tumm:kit in mrordance
iriih 1511 NCAIC OW.0100 or 154 NGEG01C,0200 MO Construrriou srwtdar rs and Mar a
7.Ls this a repair to an existing well: rilYes or KINo 'espy of Mir ro'ord bat becnrpinvided s's:kn sir►l onnt'r.
If th(s is o irl'air,fill rat kotnrn well construction Information anti rtplaht the nrwxre of the
repair under OP lraaarts ires'an ar acre flit back of this forma 23.Sitediagram or additional well details:
You may use the boa of this page to•provide additional well site details or well
8.Nutt:hero('wells constructed: 1 coustmetimt details, You may al::o atlaeh additional pages if accessary.
For*mul4ple infection or aryl-hater supply trolls ONLY with the some ctrsirurlion,you coo
.snbutirone form. . SUBMITTAL INSTUCTIONS •
9.Total welt depth below land surface: 34 ((l,) 24tt. For All Wells: Submit this-fonn within 3U days of completion of well
For multiple weltslistalldepthi(fdif,'went(txemplc-3€2(ul'and2,@100) eonstn,ctianto the folio-sing:
10.Stank water level Leltiw top of casing: 20 ft) Dh'itriun of Water RcsourceS,information Yniccssing Unit,
if water ball is above sin;are"+" 1617 Mail Service Center,,Raleigh,NC 2 7 69 9-16 17
11.Borehole diameter:6" . - (in,) 24b.For Infection Wells ONLY: In'addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of.completion of well
12.Well eOnsteuetiou(method: sonic constnictiott to the following. i .
(i.e.auger.rotary.cable.direct pastime.) I
Division of Water Resources,Underground Injection Control Programs,
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Service I Center.Raleigh,NC 27699-1636
13 I Yield(fiprn) Method of test: 24e.For Water Supply Se[flied-Ion Wells:
Also submit one copy of tills fowl within 30 days of completion of
13b.Disinfection type Amount: well construction to the county health deparimratt of the county w9Km
constnicted.
Farm GW-I Nonit Carolina D.panntrru of Euvirommtu arui Natural Resources-Dirislon of WalcrReotrcc Revised Auknst 2013