GW1--02785_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD Furtrstcrnal use ON.Lv:. .
This farm can be used for Single ai natttiple reells,, .
I.Well CDututctor toforniatioa: •
:11.WATER ZONES _ .. .
Stefan'Smith ' . . . � .. `" ; Foom. TO hRSCRIPI1INt -
1clCyrxnaorNamc• 'C..
; _ i�l it.
H .it. .
•
3576A MAY ' _U t Oft. ft
, '
UTERCASING traretutIi-casedscetls)OR LINER Iif-ap Ileabte). '
- NeWel1CotdmctorCcrlifrcatiooNwiibi
FROM •TO DIAMETER, TiIICKNECS• __ \1ATERIAL.• _
SAEDACCO ttl vi�i� i. ' -'---;•1: (Si?k 0 IL .9 rt. •2 in,i SCH-40 • PVC
�.".'y U -�':lv - - :t6.INNER CASING OR TUBING rLermu1 etased-loaf '
Carnlrmtj Naaro: °
_ ':FRO\i. TO• DPA:t1ETHR Tf1iC[CNESS :VL4TEnIAL .
. 2.Well Contraction Peituit R: - .- ft. - it:' . in: ' .
List all airli[nble well pci><rits,(L..Cmrnt i.Sure:d$rian re.li mi rrt esi_)' -
if.. ft. 'irk. '
3.•Well;Use.(check Well accj: t7:Sti:Itb:EN
%• VaterSnpply VelL• ' - — • . - FROM.• . 'TO •DUNETIR SI,OTSin: TntCKNtSS. I MATRRIAt.' '
- CDAgtieultutal• ' "Diriunicipal/Pitbl'ic •. • "•
9 ft. 19 ft; 2 in 610 SCH-40 PVC
®Geothermal( eatingKaolinS Supply) ©Residential Water Supply(sinb e) R R . in'• .. . . .. ..13kidustuallConunereial . OResidential\Vater•Supply(shazed)-- _. oGROtdT•,ru MATERIAL E\tP1ACEMENTMemoDdt:UYtotrvr .
❑frti ntion . . . , . . R. R. .
- - Nap—Water Suppli Welt::
'R.. 1L:
• monitoring- IRccoscl)'• . .` " - .
. : - •Injecttott:Welt:; . . . . . • . ...R. - , ft. .' . .
• ElAquiferRecharge DGrounditatcrReniediation • . ;I9 SAND/GRAVEiLlACK(ifappliegble)-• .
FROM'•' ' TO' - lfATIiRtAt, • - It\IPI.ACFMii:Nr MFTn0n -
' 1IArfoifcrStortnc and Rccovely EI&afinity H;itiicr' . . . ft; . ft.. ;•. .
f]AgtiifcrTcst . . OSionn atertir►iiiagc . . • - ft, f[.'
C]Rxpctimatkd TalinotOf;t' i7Srtbsideilcc Contra( •
'
-2o.MULLING LOG(attach additional cheetS,if�cessarcl
'( eotltnalClosdLoop) ' . .CTrtc . - .FRo�t •T) - DESCRIPTION
n%knuemii r '
OGunthettnal(Heating+Cooliiig Return) .,1:10dier(e'piaiit under.#21 ReInIII S1 0 :'ft. 19 ft:: silty . . .
ft. • ft:- • ..
- . 4.DateWell(sjCompleted:'4/9/24 .SYcilijiTMW-1- ' . •
•
Sa;Well Location: it. .
Citgo • R. n
.
FacilityktisucrNamc. ' . . Facility ltik(ifappl:blc '.
_ --
•
• ft. ft
. ' 1204.River.St.,.Wilkesboro, NC, 28697 . ' fL.
- Plry-steal Address City,and Zip• � •
•I L Rr iILARKS
Wilkes temp well :•
•
County i!aecd!Joint teitiou NO,(PIN) i ..
5b.Latitude arid longitude in dcguces&minutcstseconds dr decimal clegi Ces: 2L Cer'tit[CTtign
(itmell 8.kl 4oa I.W7arig iS suffieicill) • • - .
36'.141850. . ' N' 81.176753 . . . . . . w"' ' . - 4/16/2024 "
SigtutJ Ccl.riled Well contractor' : ' Date
6.Is.(ire)the N'e11Qs}:.EIPevinanent: :or .InTemporan' 11�tigmn this farm,'(herds error.Auer she irr11(a•)t+rs Own)cs.tr niered fir sc:Ford/Fe-
iiith I SA NCAC 02C,0100 or!5A NCAC(r2C,0200 WO Conitnkriaie Sksr lards and that a '
7.Istlasa repair toariezistingn'ells' £7Yei or "ONe - riresiyOf Mil woof ias Non prurldiilro Ike lira i'wirr.
1/ihi;ds a erpalr;fill east Apulia well coagrnrcrtadbrforrrrarlun awl explain to aflame oldie .. . •.
repair rirad.r 021 temarks:ieciiair privi the bail of is form. : • _ 23.Site diagram or additional will derails:. • '
• ' -- You may use the back'Of this page to.provide additional well site details or:well
8.Netnherof.itilis cunstrticterl: 1 . construction details. You iliac also attach additional pages if necessary.
For malrlpdc lrtfecilon or aovr-roarer siippii-wet(s ONLY whit die same corrstruerdorr.,t'ori roil .
sakdr One form.- • - . ' SUBMITTAL iNSTUCTiONS 1, .:. .
•
• " " 9.Total well depth bet-ow laud surface: 19 (ft,) 2aa.•For Alt'Wells: Suhnrit this-tonn tiitilit 30-days of'completion of Well •
-
• For malrlple ricllslisrall dtprhs IfdOirent(example-:@200 rrnrl20 i0O) conctmctipn to the fpltoennrg; ' ; •
Ili.Static water level below top of casing:'17 {f1L) . : Div ion of Water Reirnure w;Information Processing Unit, ' . "
iflwusttlevelisabove alarm:ate"t" 1617Alail Service Center,Ralcict,NC2 7 699-16 17
8.25" ,r ,_
II:Borehole diameter: -• (ia,) 24tt.Frir`titicettoit Wetly ONLY: In addition to sending the form to the,addr»in
24a•above.also submit a copy of this folio within 30 days of.completion.of Well
' 12.Well citrateuction-nlcthod NSA . • cotlstmctian to the following:` I. ,
(to:auger,rotaty.cabte direct push.etc.). . '
` 'Division of Water'Resources;ITnderground Injection:Control Ptve am;
FOR WATER SUPPLY WELLS ONLY:-` - • .1636 gait Ser%lcc Cc r1cr.Raleigh,NC 27699-1636
13a.Yidd(gptn) • 2 'Fo -Water Supple&Injection Wctts: _ . •
ticittadaftcst: Also submit one copy of this foci"w•rbin.30,daysofeompletionof
I3h.Disinfectiontypc • •,amount: • well constriction to the cotmty health'department orthe,county.w'hcrc-
constntetcd.
Fami GW-t . . • .North Catallna 0.gm nrcnI of Eiwirotuocm and'Natumi Resources—Dicisioo of Water.R .au'oes . • , -Revised August NIA
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