GW1--02281_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD Far frQerualuscoxtV:
This foimcanbc used for single or multipk wells•.. "
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I.WclIContrtctor information:
:ta:«ATER ZONE'S
Chris Buffer ., . FROM ' TO DF5(RtPTION
• ttcliCoMnd6rllantC. • ft,. • ft. • I !'
4223A •
-fG ft.,
' NCWdICaslractorCcriificoliooNwthcr - AS.OUTER CASING(forme tli-esedwcnsi OR-LINER titan ncabk):•
• FRO]! TO -• - PP.MW.TER i TACK?ESS• MATERIAL
SAEDACCO - ft. rG is
Company Nanie: . - -, 16.iNNER CASING OR TUBING(geothermal cfuxcd-tong). •
. •FROM To, DtA.ti[ETER ! 'THICKNESS MATERIAL '-
2c Well Construction PctTitit R; 0 R. 23"- ft, 2 .in: sex-40 • •PVC
• , LW aft applir1Ibk w.•lI permits fee.County.Stara,Variarxr./ge tian efr..;i. •ft. ft.- ht.
3.Welt.(sse(cheek well use).: • c7:S:REIN
Water Supply Well; FROM.• , TO DIAMETER SLOT SIZE THICKNMS- MATERIAL,
• 23. ft. 33 •ft. 2 In.• 020 SCH-40 PVC
LDAgticultutal Iih1unicipatiPublic- I
i •m>al(iieating/Cooling Supply). ©Residential Water Supply(single) ft. ft. in.
•
®Geaihe .
©tndustriaUConintcrcial ®Residential Water Supply(shared) • PRo OUT TO MATERIALi EMPLACEMENT SlEitloD,igt AMOUNT' •
❑Itiipalion '0 • ft. '16 L .rG Portland I Pour '
Non-Water Supply Well:,
ft. ft.
➢OMordtnring ORecovcts'
. - -Injection Welt: ft• .ft. -. .
•
iJAgitiferllecliargc lJGroufidw:tterRenlediatidn ,-I9.SAND/GRAVEL PACK(ifapplie:tbte)' - -
'' tiros! • TO' MA'rt.RIAI. I-' . I:M Mr:EMFIA( ENT rtiOD 1
l7Aitnifcr.Stotagc and Rccoycly I]Salinity Harrier 21 • ft. 39 ft. Sand #3
OAipiiferTest 17Stormwatcr Drainage• :-
ft.. ft. . �,
CExperinicntal Technology , -- EISnlisidcocc Control
• i-2e:DRILLING LOG(attach additional sheets if recces-cam' -
DGeothenuat'(ClosedLoop) • lJTr,ieer • ,' . . I .FROM- To . DESCRIPTION rrwur.lianlnevi wn'nickirpc.toinBrie.de.i .
. iJGeodtennal(Heating/Cooling Return) 170tlter(explain under r12t Reloads) :ft. . . ft. ' •
. fG• ft. {{. ,i.. ' a i i,a ). . rr
3-14-2024 MW-67 I ,'t °F h l 1 •
4.Date�Vc[I(s)Contplelcd: EYcll IDi1 rt, rt. i .
3a.Wc1l Location: ft. See Gqp's Notes j� �( �U2�
•
Cintas• rG_ ft.
Factlity.Dit'rerNante. Facility ID„(ifappikable) R, ft.
Gtf;Q/30(;
610 Woody- Dr., Graham, NC, .27253. ft. • R: f '
.P1 ssiOal Address.City.and Zip ..,I.RE:h1ARti:.S
Alamance - Bentonite seal from 16-21' .
County . Parcel hk ilifccition NO.(PIN)
Sti.Latitude arid laingitude in ttegrceslminutesjsecnnds or'decimal degrees: 22.Ccrtiticatiou:. '
((tsCtl field,oo:l•alllotn Is sulrcicill) •
,,,,
• N W ChrisRuffer 3/14/2024
• Siam uri of Ccnificd Well Canlractar • Dale
. 6.is(are)the.R'ell(s):.x Permanent, .oc DTemporary • ay signing Air fasmll betel}'cersifv that Me yell(s)mu form.)iwnrrrucud hi acrordancr
' irith 154 NCAC O2C(lift)or 154 NG1CO2C.0200 Well Constrnrt(oir Srairdards and tier a
7.Li.tins a repair to an existing well; L1Ycs or t{INo cony of this record has fh'Cn'prol'idc4 iv rthe sirll owner,
Ifthis'll a eepalr;rat oarkivouvi well connnrct(oaairfarmarlon oral evplaht the;wrote of the
repair aader$21 rernarkssrc:ton or on the hai-L of thil form. . • .23.Site diagram or additional well details: •..
• You may use the back of this page to pros'ide additional well site details.or.Welt ,
• - S.1lumherof wells coasttucted: 1 construction details. You May also awl udditiottal pages if accessary.
For oiuhipre lnjecilon Or non-water supply bells ONLY with the tame eanstriktlon,you con I'
sattnilri ieloran.' - - - SUBMITTAL iNSTUCTIONS.• • .
. 9.'Q'otal well depth below hold surface 33 (fe,) 24a. fair AU Wells: Submit this•form within 30 dams of completion of well .
For multiple welklist all deptlu(fdif,''earnt(rrmnpfe-39.200'and 24,100) construction to the following:
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• Ill:Static water level below top of casing: . (ft,) • • Mishit'of Water Resources;Information Processing Unit.
If Hoke beet Is above easfitn;rue."+" . "'1617 Mint ice Center;Raleigh,NC 27699;1617 •
El.iforehole-diameter.6" (in.) 2-lb.For Gilectioti WON ONLY: In (ddition to sending the fomt to the address in
24a above.also submit a copy of this font)within 30 days-of completion.of well •
12.Well constc[ietion'methodi Sonic construction to the following:• • 1
(le:auger:rotary,cable direct Fisk etc.} • I• ,
'Division of Writer Resources,Undeigrotntd Injection Control Program; •
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scn9ce.Ccnt$r.Raleigh.NC 27699-1636
/3a•Yid((gpm) Method of test: 2da-For•Water Supply&Injection Welts:
Also submit one copy'of'ibis fano'Within 30 days of completion of
13b.Disinfection hype: - Amount: well construction to the county lrealtil department of tlic•.counh'-w•1 ore
' constnictcd.
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Form GtV-I North Carolina Dclierniicnt of Euvironrrcra and Natural Resources—Diets Ma of WaterRmirci Revised A[gustl*l3 •
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