GW1--02744_Well Construction - GW1_20240506

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- • WELL CONSTRUCTION RECORD Far treenail vscoNLY: •
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This form can be used for single pa multiple wills •
1.Well:Contractor Information:
`t1:WATER ZONES
Stefan Smith ' . - .. FROM . .TO • 'DEKIIIPT,ON I ` ' - .,
Wen CoutnaotNante. • • R.' ft,. . II II . . • .
3576A ft. ft.. ! !. '
NC;VCR CaNnreLarCcrtifocatiori Nuri Ver • • • •
:tS.O[ITER CASiNG tfor-match-cased itells}OR WYER drab-ticabk)-
. . - - - FROM Tt) DIAMETER.,'' ' THICKNESS• S MATERIAL
SAEDACCO - • ft.• rt.. • la.
Company Name .I6..INNER CASING OR TUBING(eolberoial etosedaoap):•
'FROM - ,TO- DIAMETER. TCKNESS MATERIAL-
' 2,WeltConstruction Penult t#: . . . •rt., R. :ft:^ UI
list 011 ary'ilicaf k,nrh permit:(cr:County:Stme;,Uariauce.Injection etc)' • .
• • ;R,• ft. I. .
3,Weli.tsc(cheek well ucej: • t7:SCREEN
• Water Supply Well: . . . - _ -' .- FROM. . TO DW)IETER st0TSI7s: TiUICKNILSS 1 MATRRIM. • ' . •. . .
17Agmulhrtal - ' . tOMuuicipal/Public • 0 it. 10 ft: 1". in. .!.oho sea-40 PVC
DGe�othctinal.(1cati igk'Cooting Supply). '.❑Residential Water Slippy.(single)• -it`
• ft, in.
' - '©hldushialf.Coiuniercial - . DResideutial Water Supply(shared) .t8:GROUT
mom TO 'MATERIAL. EMPLACEMENT NI RIODSAMOUNT
❑irrigation - • .ft.. 'ft. '
• •
' .Non-Water Supply Well:. '
• RR. onitonnj I7ftcco}'cly R.. to t ,
M .
Injection Welt:. h, ft. . . .
. IJAquifcr Recharge' 0IGioundnaicr Rcincdiation . • �t9.'sANII1GRAVILIACK(if cpiiucabley,-. . . . - .- -
•
17Salinitl'Harrier -FROM- - TO' M.TRRWI.
ft,.'' ft. EttiPI.ACE:HENT METHODC]Agdifcr.Storage and Rcccrncuy •
OAquifcrTcst : l7SlormwatccDia page . fc. ft,
❑1 il,clenrcn(nl Tctlinolo ' 17SImllsidencc Con1wl
"20:DRILLUNG'LOG7nitach adtlll loan!'xhcelsif necesmn•t
OGeodtenual(Closed Loop) OTracer. . .FROM TO . • DESCRIPTION Robr.bomb cri...tultrock Dre..l n"srre:cte) .
❑Geotliennal(1TeatiiglCaollug Return) •❑Oilier(explain under 1)2l Rethinks) .0 .:IL 10. ft, Sand
.ft. ft.
•
4.Date WeUt Completed:•4-16-24 we.it, • ` W �'�� � `''
5a1Y1 Location': f ( MAY v lGr4 •
•
Buckeye . - ' ft, rt.
. l'actiitytini crNamc. Facility IDk(if applicable) .-- _.
•R. . R.. 1TYlCiit%'b 'CI " ::tr'L.`:y ii;il
• 4414.Buffalo Rd., Selma, NC, 27576' - R ft: Li t"
. ' PltiSicnl Address..City.ai,d zip• :2i.REMARKS - -
Johnston . . . . . . . . . . Temp well. for grab sample'. ', . •
CouNy Parcel ldeatiftcalion No.(PIN)
gb.L ttitude'alid Luingitude in dcgi'ces/minuteslsecrinds Or decimal degrees' .22.Ccetittealion: '
(itn 11 field,one utilmig Is su111cicitl} .
35.555181 ' . 11 78.297675 . - W. f' 4/22/2024
. Signu'. of .fin•d Well Contractor j ' Date '.
• G.Ls(are)the EE'eU(s)r •❑Penflanent ..or 10Temporan' ,By signing this form;'I lrerdj certify Oat ilia well(a)Ma(nrrnj sonar red fir accordance.
• • • . with FM NCiIC 02C,0100 or.15A NC4C.02C.0200 Rid)Construction Standards and:bald
7.L.this a repair to an ciistingwell: ' . OYes` or VNo (copvofriifr record hm Iwor provided tothc'srriimow.
if*tilt a ieixrlr;fill exit krmim well eout,ucrton brformarlor and e-,plah,the tgtrare of rho
'repair rimlcr&?I irtnarkvSretlao.eir at the brisk of this fprnr. ' : • . 23.Site d a ram or additional well details: - - . • : , •
• • -You may use the back of this page to:'Amide additional well site details or Well • • •
8.Numberof wells constricted: 1 - 0otlslructiolidelaits, You m ay alto attach additional page's ifnecessary.
• . •For•maltlple btlecrlot or tam-water supply rvetls ONLY with the same censirucftor,yeti Can - 1
. salmi:Of'orsn.' �UBM11TAI,INSTUCTIONS._ I! .
'• 9.Total well..depth below land surface; 20• (ft.) 2a:L For AU Wells: Submit thus farm within.30 daps of completion of Well
• For tnakiple;relic lisralldepths ifddliven:(example-3@200'amf 20/Or) constriction to the following: •-
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. 10.Static water kn'el below top of casing;3 <ft) Division of Water Resources;Information Processing Unit, •
1f 1,Ylter level Is al,ore casing;ass"+" . . -1617 Mail Sen ice Center,Raleigh,NC 27699-1617 . .. •
• 11.Borehole diamctcr.2.257 • .--(In.) . . • 24b.For'Infection Wdlt ONLY: in addilionto sending the form to the address-in .
.21a above,also submit a copy of this!foam within'..0 days'of.completion of well
12.Well coastruction'method:DPT • . • - constmetionto the follotu,g=' E '''
(i.e.- sugvr.ratan..gable direr push crc:}. 'Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • -l636 kill-service Centel.,Raleigh,NC 27699.1636
13a Yield WOMethod of test: •''de,For Water Supply&injection Wells: - •
• •• •Also submit one copy of this foimiwithin 30,days ofcotpletioirof
- 13h.Disinfection type: ' . - Amount: - well construction to the county health idep inment of tire.counlv.where .
constructed. _ .
Fonn GW-L Noah Carolina EJcjranmcm of EtwirurutLtu and Nants9 Resources-Diii;lon of WateiRmutre - Revised Atgtst2013,
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