GW1--01446_Well Construction - GW1_20240301

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` 1• `
WELL CONSTRUCTION RECORD / For internal Use ONLY:
This form cnn b:used for single ar nudtipIe wells \'\ I
1.Well Contractor Information: ` • i
:_E:rt%WT'ERZONES
Rich Lemire FROM TO DE:SCRBPinl\i
WA Contractor Nantc ft.. ft, I
2593A ft. ft. {, I .
NC Well Contractor CcnificaliotiMather IS.•Ot[TER'•CAsING(for-mouth•martWean'ORLiNER(irap)ncabk): • -
rugs! To DTAMETF.R, THICKNESS MAMMAL
SAEDACCO • f4 ft. in..
Cbngruiy Noun: •
16.-INNER'CASING OR TUBING(-euitiermnt efascd.loap)•' '
FROM TO DLIMETER THICKNESS MATERIAL
2,Well Construction 1'etmit#t .. .. 0 ft. 24 ft: 2 • ,b1. SCR-40. PVC
Lfsr all applicable welt penults,(isr.County,Srwe,.Variance,Nerd co,exc.) ft; ft. irk.
3.Wait Use(cheek well age): 0:SCREEN ,
Water Suppl Well: •
.__ • FROM TO DWAMETkR SLOTSt7A THICKNESS I MATERIAL,
ClAgricultual • DMunicipalt'Pt:blic 24 ft. 44 ft. 2 ill; :010• SCH-40 ' PVC •
®Geotlia ntal(Iicatingtdoliog•Supply) ©Residential Water Supply(single)
rt. iL . In.
®LidusirialiConmtercial ©Residential Water Supply(shared) . I:1F8RO\r: ruT .
TD MATERIAL 1 EMPLACEMENT METHOD SAMOUNT
❑Irrigation 0 ft. 18 IL PORTLAND POURED
Nou•Watcr Supply Well:
EIMonticrring lIRceovety , ft,:
Injection Weft: rt rL ' •
[l Aquifer Recharge 17GeoutidnaicrRcntcdiation 49.SAN0!GRAVEEPACKiifunpllcnhte)' - - - -
FROM ' TO • MAIKANN . • RMPI ACCURST MRfllOt1 '
IDAgnifcr Storage and Recovery []Salinity Hamer_ • 20 R. 44 Ii, SAND ; . #2
ID Aquifer Test , CISionmtatcrl3rainage R. iL.
DEaperimenhtl Technology ❑SRbsidcnec Con1tul :in.'DRILLING LOG(attach adilitiortal-sticebc if nccescarvl
❑Geodie:mai(Closed Loop) • ❑Tracer, FROM TO DFiCRwPtiON(cobs.Nether..wRwKtr t,ne.r, n:be.rte.}
i7Geotlettnal(Heatiltg/Cooling Return) 'milker(explain under A21 Retuatks) 0 ft 34 tl BACK FILL
• - 34 ft: 44 ft, PWR ,._..
4.Date Weil(s)Completed: 1-16-2024 Well iDt1PZ-3W _ -' _ :1�";7—-S%•
511.Will Location: ft, iq MA q
l y Y U�n24
Toyota , ' ft. ft. YI
Facility,+DivrnrNnaoe Factiity ID#(ifappli able) R. ' rt. • • twor5'w.4F`:1 PraC000kva
5938.Julian Airport Rd.,, Liberty, NC,. 27298 • ft. ft.. - Win' o'
Physical Address City.and Zip• .21:RENARIcS'
Randolph BENTONITE FROM 18' TO 20'. •
Cooly •
Forcer ldcrdirieruon No,(PIN) I, ,
Sb.I.atihrdcand 1.tingitude in degrces/minutei/sccands or decimal degrees: 22 Ccrdfeadnn:• '
(truell field,ow latnoug Is stdnekal) �,,w, ,i
.22... .
N W f/1F/}�+�..4. 1/20/2024
SignatureafCea) Weilcantlxtar i' Dale
G.Is(are)the weli(s):.RiPertnattent or' I:Temporary '
if aignbrg dui form,1 lrerOv curly dun Mr'trellis,MN(Mere)canonicity'in accordance
with 1M NCAC.02C,0107 or l5A NC.C102C.0200 Mil Construction Srafsdards and rha:a
7,Is this a repair to an existing well: DYeS or 19ND 'eeprnf Mk record has perm pr n*k l to.lie Teti minter.
1101's Is o rt tir;fdioa('Wiwi,well coosrnicrlaa lofomnr1on awl avplafwrhe turrare of the
repair cinder 02l ie'narks icctfon ar ia,the boa of this for.6. 23.Site diagram or additional well detaits:
You may use the back of this page to.provide additional well site details or well
8.Number of welts constricted: 1 constructioideuiiis. You may also Oath additional pages if necessary.
For nralydple lrtfec:1m or non-rarer supple wells ONLY rrlth rho snore ctnrstruthon,you eon
=OmitMir foram. SUBMITTAL iNSTITCTIONS
9.Totalvrelldepth below land suti8ce 44' (a.) 24a. Fur All Wells: Submit this form within 30 days of completion of well
Formnlrfplricullslista(ldrpthsifdlfwent(cxampre-3E109'arul'3@l00) construction to the follotsing; I. •
10.Static water level below top of casing 35 '{ill.) ' Divisian of Water Resatirecv,Information Processing Unit,
if muter level is above casing,we"+" .1617 Mail Service Center,Raleigh,NC 27699-1617
11,Dorebote diactrr:8,25" '(In.) 24b.For injection Wells ONLY: i mn addition to sending the form to the address in
.2.3a above.also submit a copy of this farm within 30 days of completion of well
12.Well constrttctiort method;NSA construction to the following_ {
•
(i.e.auger.rotary,cable.direct gash etc.} . {
'Division of Water Resources,Uudet-grouud Iit]eccidn Control Program,
FOR WATER SUPPLY WELLS ONLY: • I636 Mail Service Center.Raleigh,NC 27699-1636
131 Yield( tor) ,llcdlod of test: 2 fe.-For Water Supply&InjectionlWelts:
Also submit one cop), of this feral'Within 30 days of completion of
13b-Disinfection hype: Amount: • well cottstnlctitnl to the county Italia{department of the county.where
constricted.
Farai GA'-t Noah Carolina Department of Eneirotmiiu and Natural Resources-Division of Water Rmirei, Revised August Ito t3