GW1--02462_Well Construction - GW1_20240423

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•WELL CONSTRUCTION RECORD .. • •
For[mental Uw•ONLY:
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'Tilts form can lx-usc4 for'single Mr multigile wells• . ..I .
l'..'Phll•COutrucharltifortitatiott: .. • • - .
, . -;,timAteR.2.0NES-: • .,. . . •K.-, •
Stefan Smith FROM. ' ' 'TO - 1/ CItIPTI9N .. . . .
Will ContractorNarno -- ft. ft.. . I 1 . '
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3576A . . . .
NC Well Co ntraetor Certification Number: .- IS;OUTHFCCASINGAbiqiittliklielfifellsVOR.L1NERlitati'TICA-bleb. ,_"" . ' •
, ,EROS! ' TO ' • DIAMETER TRIMNESS MATERIAL,
SAEDACCO .
' . . . 0 . ft., 13 ft,- 1" 1,•til.• SCH-4 0 ": PVC
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. campaily tia„,,.. . .?:16ANNER CASING'ORXUBINGIO,CptherioUl'elOSed-hin,q,',.' ..:.• , .. - ' . '•
• FRONT TO ' ,...DIAMETER'• ,TRIMNESS MATERIAL
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.2.'Well ConitrutittittPerinit i:'wmo 7°1315 ft, • 1:•'ht. . •
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' . hh.t4ril.4,411470k 5441 pentrits(LC:Counr2.,...1rure,'•Vorforire.Irjectial eird. . . . . •
. •ft. ft.- - 1 ht.. . . , ., • .
3.Well.Use(etteelt Well use): ' .s:17:.S(REEN' - " -'' ._,,. . .
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.. ' . IiinterSupplyWell: " - ' - -. -- - FHONI• TO • DIAMETER, SLOTS1D: THICKD MS ! MATERIAL' •
• • • • - •• • - , 13 . ft. 18 :ft.. 1° ill.i •..010 SCH-4 0 I PVC
. 0 Agricultural . . ._ , lnItaticipal/PubliC:
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EIGeothemtal aleatitigicooling SOpply). • EIResidentiat Water Supply(single) . 11 , •
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• . ' CI industrial/Contnietcial • • OResidential•Water Supply(shared) -.-71.FilioURNI,°t1T''40 .. . mit-TE .. , • .
EMPLACEMENT METHOD&A-SIOUNT .
01rtiOation ' • • •
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• -.* NOti-Wattr Stipia Well:: - . . . . .
R. . . ft.
filManitoritig . • - , .-011ecoveTY ••• i . . . . . .
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.. . Injection Well: . . ' - • - It.
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0.AmtiferBecharge.- iiatounditalet Rentediation -i.tc:SAND/GRAVEL-PACK(if aliplkilito)'?- - -- ,.-_-"_-,•,
PROM'. TO ' Numurm. - ENIPLACEMENT'METHOD
tiActuifer Stomgc,and Itecovcry: DSalinity flamer. . ' ' rt. .11. - i
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. .. Test • . . for valet.Ontitta&. ,- . . . - - . .
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' - • ElExpetinicutal TeChnolog,: - EISuhsidence.CMarol: - • . . . •
. . '.10:4$RILLI-NBIOGIallacti'additional sti&ti-ificecusani •. •""• . - - •
• . EiGeothertnal(Closed LoOP) - • OTracer . ..PROM TO • DESCRIPTION(Mor.hinlne.ti.ituDInick tiWorsin ate,tit.). .' .EIGetultennal(fleatinelCoOlIng Re(urn). 1:101er(explain under 421,Retotas) o -.. .ft.• 18 (t. Silt : - • • "
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4'..Elate.Well6)fainpletedi 3/12/24 --Well MIMI'3 : - - - . •
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Well Locution' .: . APR 2 F
A... fL• ',
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Speedway . • . . . .• ft.' ' • ft; ' :' * ,....,-..., :-.a7,...t..7„.•4ir.,;?
td.9114/.0W9Cr-Natuo . . Famlity I1P-(if applicab10. - - _r,•_., • '' . r.
,, • CrV.11.4-.:f›,..1
fi. p
- 612 SW Greenville Blvd., Greenville, NC; 27858 ft•. . .-
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• . Physical AildiCss',..City..itrulZin
- '21.-.-REttlAio--.S-• .1 --- . . _ . , .
Pitt * • ' • • . , ' Grab sample collected via 1" PVC temporary . •" •
' Comuy . - Parcel ItIcAlificallon No:MN) - well- . 1, - •
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'Mk Latihtde andlontitutlein degreesiminttreshciondsOr tIceiMal degrees:' ...;,... r• ....v. .4..
:..r. 1.:Aei gl,reaw.a: •
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Of well fiCI4Unalatilokig.i.s:aullielmil) • */• •
35.572488 - . .--& 77.398270
.1, 1.;L- AA 4. . , 3/26/2024 . •• W .:..,—.0,.......0 , • -
Stroh of C dyeell Contractor 1,' Dale
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6:4.(are)1heiwell(s)i LI.P.ertioanent or xlTeniporary . . .tij.signing dutsfeena,1 Irtiwby evilly n!iiii ihg:we'll0 WCIS f wdrrycortryded it af.11.'0.11/61Ce
• . . . . tri;J:t•15et aKAC OX'.9/00 or/.14 NC.,I.C.02C,,0200 Well Constukticut-Srangtials.nq IIMIS a . .
. ' 7.-Is this an:pale to aacxislitig.wolll. bYo• or -CO No. . .ropy.01 this rimy,hers hveri Provided'0;MT NtWi owirrr,
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.if ibis'ha fiwnir:Al owtkreOuw.trell einutrucilort hiforoictIcitt,rile.41lain the otaihre of de. • ' - ' • ' . i .
inirdi'under p.1 ranrziki 4.1e•iii:an Ewan'th4i bark arthis.lorm. ' . ' ' ' '. 23..S he diagram or additioualwell dating - .
• -You May use the back of this page.to provide additional.well site details:.or well -
13.Number of Wells constructed: 1 • • constiuetion details. You May:also:attach additional Pages if necessary.
Foe.nu'ilti*:fitteeriori Or ooh-!tvicer shpfify iveldsChytY•Oh the soiNkcopstriallott.pa coo ' .
sufmkonclorrn, • SIIIIMITTAL INSTUCTIONS :
. • . . f'9.Total well depth below had surface18 ' 00 21a. Fur Alt Wells Sidtinit this kith'within 30 days of completion of Welt
For maidploiridltILirliff depths If di,#i'rent eemir104.,-3@201rorl 20'NOT constiliction to-the following:
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10.Static water level helms top Of easing: • (ft.) Division of Water Resoure6,Ittfitrmation Processing Unit; •
lf Ittibir•lentil h'above rosimpse"+" .. • 1d17 Mail Service,t Cuter,Roleigh;NC 27699-1617
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. IL Borehole dianieter-1.2•25' .0n4 • 241.}.Far Infection Welts ONLY:, ihi addition to sending the form to the address-its' 24O•aboe.also submit n•copy•Of this fano within 30 days'of,completion of well
• I;.Wc11-cottstructibil method:DP T - - . . e:004.01di 0ii tO"thefOLIO‘Vilig:. 1
(i.e.pugsr.joility.=WO,direct rush,etc) I I - • .
'Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY .1636 AL&Service'Center,Raleigh.NC 27604636
24e.For Water Stteplv&:tn_licellou Wells:
13a;Yieit1kpot) Method ottest: •
•Also submit one copy-of this form within 30 days of comPletion of'
13h.Disinfection type: Amount , •: . well-constniction to the.county helalth department Of the'eon*where
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•con.stnicted.
. Font GV..1. • &Doh Carolina ficpartment of 1:111i1011.11X111 artgl Natural Rcrourees-Dhir Ion Of Water ilMoiras - Hevlsed August2013 •'
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