GW1--02464_Well Construction - GW1_20240423

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WELL.CONSTRUCTION RECORD'
, Far Internal Use ONLY'
•. h6 form can bcuscd for single aimultipk wells••
I.Well Contractor inrormatlott: - •
F,14:-ititR.ZONE.S. i..
Stefan Smith . FROM. ' ' .TO -' . DESCRIPTION '
• Well CoritactorNanle . . ft.. •• . ft, I .
• 357SA ft. ff. P
NC W.IICantractorCcriliEralionNurn tci a15dOtffER-CASfNG'ifait;eiuill-casediiensi'OR LINER(Cfap Ocabk)k ..
,.FROM' ' TO - DIANiETER THICKNESS M'ATER'Al.
SAEDACCO .. 0 ' • fL. .8 ft„• 1" i''jn,_ SCH-40 PVC
Comp;ml•biainc, . 3:-1 INNERCASINGORTt1f3ING(Ovlbcrmlctoud-toq j;x4',__.. , .
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-FROM- INTODIAMETER- , TIRCKNESS: - MATERIAL
Y.Well Cons,ut tiiin Pel'Rlit nt WMo 701315 • -R. • ft. •lit. .
fist all rtlpilicat4,.icellprrnrits(rs.County.-Sutr,Lurimire..4ect Grt.fir).. It.. _ ft: • i. fa. -
3.WVcll.Use(cliedcwc11 WO: --:1*K SCREEN." - .
WaterSupph Well: — •- m_ . - .FROM• . TO • -PIANt:TIM. SLOTSI? TIIIC/iNESS MATERIALl
' ClAgrietfltnrat. • ,inhiniticipal idiC: 8 ft: 113' ft. 1" ln`; 010 SCH-40 PVC
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®Gcotttemial(iieating/Cooling-Stipply)- ®Residential WatorSupply(single) . . fL . - - ft. t°.;
' 17indusitialiConttuercial . ©Resitkntial�ifater Suppl}`fsiaated) ' 18i GROUTr,..
FRO\' TO • MiATERLtt ' EMPLACEMENT ME. TROD S Jiro] T
❑hridrition it.. It •
Noti:Watet.Supttly Well::
. R: • ft,
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®hionibring ORcco`rrs
Ittjecllott Well: ft, . .
DAtptrfcrRccharge DGroundnatcr Rcutcdiation ' . 'cis:SANDlGlLLVE iPACKtif ititpllcnitk)+ . --
'NROM- ' TO MtTF.RIAt: - 1 EMPLACEMENTNo:TIIOn.
L]Agttifcr$toragc.atid Rccovet)t• : ❑Salinity lather. . R.. ft:• - r ' -
ClAgnifcr.Tcst • • IDS torinwttcri]rainagc. • .
ft. (t.
❑ rpetimcntol Tc hncl(ogy QSl]bsidcricc.Conitol :211 8RILLING LOGIattach:additional sheets iliteccssar vi ---• - - . . .
OGeotltennal(Closed Loop) ..- El Tracer ,FROM TO DESCRIPTION(cobr.lianInvs.unntek t4tx:Mxin tire,tica
• - OGeodtential(Heatine/CoolivaRetuttl) . DOflter(explain wider tat.Retnafls) o :1t: 13 • .ft. Silt -.
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4.Date Wcit(s)Coitipie•teds.3/12/24 , Well iDl1Msq-2.• . .
. ft.. fG I. •. .
• Sa:Well Loea�tiam: • • • -.ft: - ip I. •
APR 2 2024 • ' .
Speedway . . ft:- ft, I. •
lru:;;. : : ;:r
• . pacpityrYpwMi.Niglio Facility lD (ifappti able); • .ft. ft.a • i CiyTcw;Sv .
612 SW Greenville Blvd.; Greenville, NC,. 27858 ' ft.• ft, '
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• Plgsical Addt ss.City,and Zip- ,.2I:�RIMARKs.,,
Pitt - . • Grab sample.collected via i" PVC temporary -
Connp' • farcC]lrknti( nj1onNo,(P!N) well
Mr:.I atitude and Longitude:in(Iegrccs/minutcsiMccondsor decintatl degrces:' Z.�crtilicatirrn: - ' - .
(it ill 1'iekl,orte l;ttllurO i$'SullicienI) ' • -
35.572488 . 77.398270 • {' ) 7YJr%+s' " 1
• . St• an'. afC,,fled Well Couttnctet, • Dale
. . 6:I8(an.)Pewell(s): Dpennanent or ' 10Tentporat}` - B"...signiq thrs font&Ilrerebyferr1 float!giiY'lls)tray,fhtre.curastnzctedliraceonlace
with 15l-NC•4C 02C,0100 or l SA NCrtC 0 C..02017 Wei/CO1tst1Yrrticu(Sfalkiards enrl'Aim a
7.'4 thty a.repair to an existinp.n'ell:. ElVe •or ElNo .cops chi,'roronihos liven provided ladle cell onirfr. •
ifalrfsllsatrpMilrfilliwtkriaiwits•ellnnnstnrcilaia.firformatlon anderplalrt rile nitltrreoffile • 1, •
irpirirwiderP2.)remeltk.sielarraran01!bar ofthi•.fame . ' - ' 23 Site.diagrautoraddittional•neildetails: '
• 1[ou-iupy use the bacic'of this:page.to provide additional'sell site delaiis:of welt
8.Nittttber-of ru nelis constcted: 1 . • . . consttuctimi deiaits._ You itiar also attach additional pages if ilecessifry.
For ituil(fpleirt/eetlynbrami-niiretsuppiyle&ONLYri'kiidiesnmecoat'strrtet1on,gauran, '
S;u}inir.arieJorm. •STiBNIM'AL11STSTtTCT1ONS • •
0.Total welt depth helot.had surf tee: 13 (lt,) 24a.-Fur All Wells:- Subndt.this,feria Within 30 da'.s of completion of welt • '
For Jirnlrfplalerifr lift ally&ptllsffdi,'i•reiitiexariipfc 8@?OO"(ind2R'MOT cof$intCtioato the.foitening-r ,;'
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10.Static water level below top Of Casiupt - - ((1)• DivIsiuu of Water Rest uurces,Information Processing Unit, ,
/f irm r levi•J.lt above wafnf;as."+" - 1617 Mail Set•tica Centcr,Raleigh,NC 27699-1617
IL Borehole diameter:2.25 n (in,) 24b.Tor infection`Vella ONLY:l in addition to.sending the foot to the.aildt>s-in.
24a"aboi'e.also submit a copy of flits foot within.-30 days of,completion of well
12.Well construction method:DPT • cousttuetiou ta'tite following_ l
(i.e.pugcr..mt1uy,cable.dhccl Fitsti ctc.) • l
Divisiot_of Water Re;leurces,ITudergr'otProgram,urd injection Control
FOR WATER SUPPiL LS O Y WELLS 1636 Mail Service Center,Raleigh,NC 2 7699.1636
13a,Yield(gjltn) Method of test:
'Sc.For.Water-Suppl`.k injection Wells:
Also submit one copy of this.form-within•30:days ofcompletionof •
-13b.Disinfection hype:_ Amount: well constntction to the-Bounty f hdalth department of the county wheal-
constmcted.
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Fonts GW-t fool'Carolina Ciepam i nei of Enviivnnrnl and Natural Resources-Division of Water Rloutr Revised August 2013 - .
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