GW1--01447_Well Construction - GW1_20240301

t
WELL CONSTRUCTION RECORD � `''c� Forty entnlUscONLY:
This form can ba used for single or multiple wells t`r
1.Well Contractor Information:
`LL..WATLR ZONES . . .
Rich.Lemire FROM- TO DESCRIPTION Well Contractor Contractor Name R. ft, I '
. 2593A ft. ft. I ,I. . •
NC Well Contractor Ccmii®tion Nadia. ,15.OUTER CASING Roy multi raasedadctlsl'OR L1N);R(Waif A ANO''
. . _ FROM •TO Dr.4(IIETRR 1 THICKNESS- MATERIAL .
SAEDACCO rl if. I,II.
c n i uay Nwito 16.INNER CASING OR TUBING N,uthermil closed-loopy-'
FROM - TO DL+LMETRR THICKNESS MATERIAL
2.Well Construction Penult#: 0 ft. i7 ft. 2" • :tu. SCR-40 . PVC . . •
List off afytlicraGle well pennies,fi e.Comity.Stile.-Variarxe.lrffeco'cit etc.)
•R, rt. - - 'to, -
3.Wc11.Usc(check well use): t7:SCREEN
.Water Supply Wc1L: -. F�. - _ --- . .--- FROM.' . 10 . 'DIAMETER -stsTSI?F. T1ICHNESS 1 MATERIAL
LINO-cultural C114lunicipallPltblic 17 II. 37 II. 2" in O10 SCH-40 ` PVC
f7Geothenna1(Heating,Cooing Supply'} 1lResidentiat Water Supply(single) • ft, . " ft. in. I
El industriatfContntcrcial ©Residential Water Supply(shared) '-tP:GROUT. .' • ' _
FltO\f TO . MAT'ERL4L ' EMPL4CEMLNT METHOD&AMOUNT
❑fftipntiah . 0 ft.. 13 ft. PORTLAND TREMMIE
Non-Water Supply Well:, R. ft.' .
RIMonitoring O1tccosoty- .
tujeclloiWell: et. ft,
CI Aquifer Rccbargc t3GiouidnntcrRcnicdiation •t9-'SANDJGRAVEL-PACK(ifntgrllcoble . ,
FROM . TO' MATERIAL R IPLaCIYIENTSILTIIOti -
IJAiluifcrStorage and Recom:ety 17Salinity Harter 15 ft, 37 ft. SAND , #2
❑Aquifer Test ' ❑Storm atcrl}iainagc ft. R.
❑Eylelimcntal Tcchnol0gg ElSuhsidcnec Control -xu:DRILLING-LOG(attach nddilior al sbcelslf necessnrvl
OGeotheitna[(Closed Loop) • OTricer, FROM• TO - DESCRIPTION(wbr.loirtlnert,wR'myklywe. aln we:rR:I
OC,eodtettual(FIeating/Caollue Return) IJOther(explain under#21 Retuatls) 0 ft.' 19 IL FILL DIRT-
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' 19 it. 37 IL 'BROWN SILT/PWR
. 4.Date Well(s)Completed: 2-6-2024 .Well ID#Pz-2 '
rt. rt.
54.W4'il Location; _
Toyota i �' 'k I LA l�f t E D
rl, I.
• FacRiq,Disocr.Nane. Facility IDrf(ifopplicable) - rt, ft. MHR V 2024-
5938 Julian Airport Rd., LIBERTY, NC, .27298. .ft. ft.
Plrysicnl Address.Ci .and Zi •
1,-4.tr1'«4tert tPr^..^0644t:1 JR0
• p xt.REntARG4 Di.ICJ3r=
RANDOLPR BENTONITE FROM 13' TO 15'I.
County NivelttkiitificationNU,(PRI)
510-ittititdc amid l tingAttude iil degrees/nano lesisecands or decimal degrees: ,2_,Certification:• I.
(it pen skid,one bulon;is stemeleno ,
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N W l/1 i+n1..+c. 2/10/2024
' - SignmueafCeni Well Dale
' • '6.Is(are)the w•ell(s): xlPecluatrent or )7Temporary 1
ily signing thin Arno,1 hereby certify that.the vacs)was iwrral curlrn i red br accord:ram
irfrlr 1M MAC 02C.0109 or 15rt NCAC 02C.0200 Rill Constmierion Standards and d rt a
• 7.Is Ws a repair to an C4isting well: IJYcs or El No copy of char record bus beta provblyd ro the rir11 mow,
If thls'is a'epllr:fall oar krraini well cam'uurtloabrfornaudar and cipfabi he aware of die 1
repair under 021 icautrtadretiao or an the bock of this form. 23.Site diagram or additional well details:
You may use the hack of this page to;prov'ide additional well site details or'well
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8.Number of wells constructed: 1 • cons(tuctiotidetails, You may also attach additional pages if necessary.
For aen/Iplc lmfectlat orris:-uvier nrpply mefls ONLY mach the same constrain-on,yaa can -
sabmir one tom. . Sf11BMITTALINSTIICTIONS ',
9.Total well depth below land surface: 37 (rt.) 24a..For All Wells:. Submit this•fans within all days of completion of.well
For a ralriide welds'lisr aidemtlu tldifforrnt(arampfe-3@Nil'rind 2@I00) • ' - construction to the fanning: '
10.Static water level helow tap of casing: 21 (It) Division of Water Resources,Information Processing Unit,
' 1f wale,.level is above rosliag;ate"+" - 1617 MalSen•ice Center Raleigh.NC 27699-1'617
IL Burch.!c diameter 8.25" -(in.) 2Ib.For(nficl(on Wst(a ONLY: Ind addition to sending the form to tbe.address in
24aabove.also_submit a copy of this fat]within 30 days of.completian of well
V.Well coustntctiau Method:AUGER eaustmetioh to the following: ,
(Le:auger.rota:}',itnble,direct posh.etc.}. • Division of Water Resources,Underground Injection-Control Program;
FOR WATERSUPPLY WELLS ONLY: I636 Mali Service Center;Raleigh,NC 27599.1636
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13;a Yield(gprn) �Ictliod of test: 24e,For Water Supply&Injection Welts:
Also•submit one copy,of this form iyithin 30 days ofcompletion.of
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1311.Disinfection type: • Amount:
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well constriction to the county health dcpanment of the calmly where
constructed.
FormGW-t Noah Carolina rmeparpitens of Em'iraiunxni and Natant Resources-Division of Wooer Rmotrem Revised August 2013
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