GW1--02746_Well Construction - GW1_20240506

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- WELL CONSTRUCTION'RECORD . • For Nepal UscONtV: .
This form can be used Car:single or tnultipk wells, .
1.WclI.Contrnctor Information: •
^-:14:A%WtER ZON I S .
Stefan Smith . FROM ' TO • DKSCRIP-10\i
. W01 CouihicioiNnnie - ft,' ft, • 1 I ' - •
3576A . R. ft. •! I .
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NC Wall Corumctor Certification Nmistcr . . 15;000TER CASING(t'oretutli sed„ettsl'OILLiNER(tfap flcahka•
• . • FROM .TO • DIANIF.TRR, . THICKNESS. MATERIAL
SAEDACCO . . . - . • ' IL. ft.. !in.. .
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Company Nand . , .I6 INNER CASING OR TUBING tgeothermat ekusedaoop). : • •
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' .FROM TO- DIAMETER' . THICKNESS MATERIAL •
2,We I.Construetinn Perinit>r: . R.�. ft, • •
List all appil1rable toll permits(i.e.County.Stok,-Voriarree.(lethal rrc.J' R, iL to
3,WCI1.Iiie(check.iA Well use): 17:sCIUXN •
1YatcrSupply Well FROM. . TO DIAMETER stttrSIEE THICKNESS I JIATRRIAi.
❑rlgliculttual • .. . . .❑Mtttiicipal/Publtc • 0 ft. 10 ft, 1" iti .010 • SC -40 PVC
f4 : ft :in. .
❑Geothermal.(Heming'Co ding Supply); •.CIResidelttial Water Supply(single) _
- • Dlnduslrial/Cornnic Mal DResidential-Water Supply(shared) .i8:GROUT
FROM TO MATERIAL ' EAIPIACESIENT METHOD&AMOUNT . •
. . ❑lrripation ' ' ft: fl.
. . •Non-Water Supply Well:: - .
It, • tt.
itMonitoring . • .PRccovcty'- . 1
t. . It.
. . 'It1jCe110n:�VCU: ',
O'Aquifcr Recharge QGiouridisatcr Rcntcdialiou • .t9:'SAND/GRAVEL-PACK(if noolicahteY
FROM ' TO' •MATERIAL ' EMFI,ACEMENT METHOD . . .
1:1Aqui61.Stotagc and RecovcO' . QSalinity Hairici rt.. ft. •
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• . El Aquifer lest . QStornmaterltai_nage. • . fr. fL.
Q> penmenfnl Technology Q5Rbsidcnco Cotgrpl 20:DRILLiNG LOG(attach additional sheets if ft-cos-ant cnn l
: OGeotitemml(ClasedLoop) ' ' OTracer. • . :FROM TO . DESCRIPTION(tobr.hnntnec+;wn'nMktyot.irinsumtinrt
❑Geothemnal(NeatingtCaolingReturn) ' ❑Other(explain under A21Retuaths) 0 :ft. 10. ft,- Sand . . . '
rt.,. rt. -
- 4.Date Wctl(s)Completed: 4-17-24 • ,Welt IDfiTN-19 ' • • rt, • rt. t, '6.•.•a;;`) i'
5a.Wcl1 Location: 1' j .
• IL. MAY.0 6 / • -
Buckeye . . . ' ft. . . . ft. CO24
Factlit),+OitncrNanae ' . Facility IDm(ifapplicable) rr.`v,n „ rao_ .
. R. • rt. r .,�srYL.'; ',,,. . •
L .:... t�. •l;
4914.Buffalo ltd., Selma', NC, 27576 ' :fA rt. j� r"""
PltysidalAddicts Caty.nndZip z2f:REI1fARKS' • .
Johnston . " Temp well for grab sample. .
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C-oioy. - Panel Id(nlirttc,1liun No,(PIN} • . I .
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Sb,Littitirde and Longitude in degrees/minutes/seconds ur decitimi cteteccs: 22.Ccntiun:
(Ifi;ttl fkld,wa I tU7oog Is srcfnckid}
35'.555181 N• 78.297675 W : 1t • iiiind4/2 / 024 . '
- Sigmt•Y,ofced Well Contractor �. . Dale 2 -
6.Is(are)tire wells):.❑Permanent .or lTemporan' . . 2
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tfp signing thir_fonrt:'1 lrerrby rrrrsfy laar!rhe uell(sl Isms inrnl cnr;mie:red in,mreordance .
frith 15i1 NCAC 02C AIO1O or 15.4 NCdC 02C.0200 Well Constrtrrlon Srdidards and gnu a -
•7.Is this a repair,to an existing well: . ClVes or 11No - • :ckvijrof rliir word has been pmeirred_R.:br;rrr'll owner, '
11 dols'is o,('pal r;fild ear knonzt well conrrnrcrf)u infumuulon and explain Me nrtrnre of the -
repair wider s'21 innarks.irctiunor•on the boil of ib r form. 23.Site diagram or additional well detaiir, . • .
You may use the back of this page M.provide additional well site details or.n'ell
• 8.Numberof Wells constructed: 1 - ' • . - - eonvsttuctiou details. You may also attach additional j a.'es if necessary.
For maniple In jeetIon Of non-yarer st pplr wells ONLY irirh die same construct/on,yati eon
' submitone!ono. '. SLTBMFITAIJNSTUCTIONS, i . ' .
9.Totalwelldepth below lout!surface: 10 (ft.) 24a. Fur All Wells: Submit this fariir within 30 days of'completion of well '' •'
For nw/Pplc'reels-list all depprhs/fdit?reotfre.npfe-3T200'arut2@100) . " eonstnrctipntothefoltoning; - 1
. 10.Static water level below tap of easing 3 -A) bivixiun of Water Resources,Information ft-messing Unit,.
' if wane level Is above moats:use"+" I617 Mail Service Center,Raleigh,NC 2 7 699-16 17 '
I t:Durchole diameter 2'.25" (�) - 24b.for Infection Wetly ONLY: In addition to sending the form to the address in
24dabove.also.submit a copy of this Munn within 30 days of completion of well
• • 12.Well constntctiou method:DPT cofiSlmcilon to the following: 1' 1 ' '
{i.c:auger.rtrtaq,table,dirrxi push etc.} 'Division of Water Resources;Under ound Injection Control Program;
• FOR WATER SUPPLY WELLS ONLY: ''• S 1636 Midi Senice Ceittei.Raleigh,NC 27699.1636 - •
13;1 Vidi1(gptny Method of test: •
24c,For Water Sup .tic Injection Welts: -
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• Also submit one copy'of fonii within 30,daysofeoMpletion.of •
13h.Disinfection type: Amount: well'construction to the county health Idepamment of the cottttO'.where
constntcted. 1 .
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FonuGW-t North Carallnalk-xtnmentofgneitotuonii and Natural Rcsourecs—Dirt Ma or Water Reotates . -Revised_lt ust2U13
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