GW1--02742_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECORD Per it¢e Mal ttscoNLY:
This form can be used fir single or tnultip)c wells„ -
I.Well Contrtctar ltiformation:
• -W:.WATLR'ZONES• ,
Stefan Smith FROM ' TO '• 0F_S(tRIPTION
. ' •. -Well Cor(ractor.Nante . . ft. ft,.
• 3576A •
ft. ft.. i
NC Well ContmctorCcnification Ntuilicr ' • ='13.OUTER CASiNG(for maul-imed hcIls)OR LINER(tf not ncable):
FROM -TO . • DIAMETER.•'• TtIICKN-ESS• MATERIAL
• SAEDACCO - . ,ft, ft.. Jot.. • '
Cnttyruhj•Iidnro
16.rINNER �
CASINGORTUBING eonbernia{cfased400p)..•'
. FROM TO DIAMETER. THICKNESS MATERIAL
• 2.Well Constrti thin Permit#: . ' . . ' . . •R. . . ft: . .
- 1Jsr all upplicublc writpenncits(ix.County:Stole,.Variamre.LfeCDc4.c:r••J' . .
`ft,, ft.- - .'in.. . . .
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• 3.Weit.Gse'(cheek well use),: It SCREEN •
WaterSnpply Well: - -FROM. . TO .'DIAMETER kOrTSIZE Tit1('KNt\s MATERIAL - - .
DAgliculttttal . 11M&liicipaVPttblic 0 ft. 10 It-1" • in;• .030 SCH-40 • PVC
= ©Geothein al 011eating,`Cooling Supply_}:. .17Residentiat WaterSupply(single): - ---it , , ft - . :in, • . .- .
•- .i ktdustrinUConlniercial ' . -©Residential Water Supply(shared)•
ts:GRo[rr . _ ,
FROM' TO .
'MATERIAL ' EMPIACEMBVT.I,IEr110D&AMOUNT
. ❑kripation . - 'ft, ft, i•
lion-Water Supply)Fell. .
Monitoring - DItccosrly R., fa' •
•
injection Wello- _ IL ft
Dl Aqu ifer Recharge • G]Giot ndw-tter ilonicdialiou . - 19 SANND]GRAVEL•lACK if appucnbta l•
.FROM ' TO MA'rRRLO.' , EIPt.AC}:MENTMFTILOn '
DAquifcr.Storagc and Recovery •FISalinity flamer , ft.. ft.. . : . .
IJAquifer,Test ASlormwaterDrainage -ft. life
1:1RyrGltmen(91 Tpcli[tplpst 17$Il65idCnGe Control. DRILLING'LOG(attach additional shce(sifnrceesanl '
DGeodiennal(Closed Loon) l7Tracer. FROM- .10 . : DESCRIPTION tcabr.hartl nevi.wn'rrtekttpc.rgnin rim trti
fGtwAteitttal(HeatingfCaoliug Retunr} CDOtlter(esplairt.uuder!)21 Rettialks) 0 . :ft- .10 ft. Sand ,i;
ft.. ft. • .. ' _ •
4.Date:Well(s)Campleled: 4-16-24 Well IDff TW-13 • ft. ft,
;'4 1.;,...-A.....,
�A. ��
Sae Well Location: • , •fL ft.•. MAY 0 6 .20Z
Buckeye eft, , fl, -
. FactlitylOivnerName . .Facility TOO.(tfapplratble)
• it. . ft. Info . ...e ,1 C•se es.g U;4.
4914.Buffalo Rd., Selma, NC, 27576- R. rl. 6iv1.rt;:iUv
- Nike'Addicss.Cary.and Zip'• =.21:R•LM1LtRK.S:
Johnston ,Temp well for grab sample,.
County - Pareel Id.iitinealieu No,(PIN)
5b.!(-iititudcalid Longitudein degrees/minutes/sccQndsor dscunstl itcgrccs .22.CcrtifeAfon: .
(If pelt field,ptr,hat/lo ig Jr Std11 rtty .
. ' . 35.555181 ' . .I\ 78.297675 W. • fr 'i 7�/"u"" • 4/22/2024
' . . Signet-..ofCc.BedWeltContractor - ' . - ,Date
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6.Is.(are)the 1Yell(r.):.❑Pertnanent.. .or /0Temporars' •11y bigotry;this fonrr;I berth),e,errify that the wets)I-u (nrrel ttms:nrc:cd In atinorduace•' - '
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Wei 1.4ileVCr{G 02C,t7/tk7 or f sA NOWQ2C A.t?P t}edl Cousrrrnrrfcmr Srarrdards and:lktr a7.1s this a repair.to rut existing limn.: ElYes or I lNo • cepix'offlict recordd bcs Iron p:waled•to:lid i -ll carrier.
• • Ifrftfib a reptdr fall antkrtmrva well eaasinrcdora:inform:don owl eapfahr the/ aare of tae • ' ,
repair rarJer01 rrmarks,Srrtrun oc an flu bark rilthis form. . ' - . .23.Site.diugr•um or additional will dettillk - '
You may use the back of this page ton pies ado additional well site details or%yell '
' 8.Nontleroiwells consinicted: 1 • constnlction details. You iliay also attaettadditional pages if necessary. .
For m:ilrlpie ir{fecilon or flail-matter sapplr wells OA'LY WW1
die same construction rani con I
submit one p i ' • SUBMITTALiNSTUCTIONS i, .
9.Total well depth below land surface; 10 (ft.) 14a. For All Wells: Suborn this•form within 30 days of completion of Well ' •
- -For multiple lIs lisrafldrl+rlts ifdifferey((erample-3@20Waw(2t1Ptt) • - constnnctionto the foltotsing:
• • 10.Static water level below top of casing: 3 .•.(fy,) Division of Water Resources,Information Plncessing Unit, . •
limpet level'Is above wens.:use"+" 1617 Mau Sers ice Center,Raleigh,NC 2 7699=1617
11.Borehole diactcr:2.257 • - (in.) . 246.For Infection Weill In aud
ition dition to sending the form to the address.in .
• • ,24a above.also.submit a copy of this farm within 30 days of completion.of well
12.Well consltuctimi method:DPT • - - c'oiuim6[ion to the following,-
(ic:anger.ratan..cable,direct Posh etc.) • I l: . - • ,
'Division of Water Resources;Underground Injection•Control Program; '
, FOR WATER SUPPLY WELLS ONLY: - • - 11636 Iliad Seri•ice Center Raleigh,NC 27699.1636
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13a Yield(>;pnl) Method of test: • •24c.Fe.Water Stipp s.li Injection Wells: ' • '
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• Also submit one copy this foiyltisithin 30 daysofcompletion.of
I3h.Uisinfeitiun type: Am aunt: smell=consrniction to the county licalth'department or the.county.where
• _- constructed. •
• Fonn_GW.t Noah Corinna Depanntcnt of Envimruisun and Natural Resources-Dlussloo of WaierResatrces Rcc•ised Atiguyt30I:t -
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