HomeMy WebLinkAboutGW1--03011_Well Construction - GW1_20240520 i
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WELL CONSTRUCTION RECORD
Tlits form can be used for single or multiple ssclls
1.Well Contractor Information:
14.WATER ZONLS
Scott Hunt, Jr mom to DItifRIRn1N
Well Contractor Name 25 ft. 38 ft. tight saperlite with sand tan
N. n.
4561
NC Well Contnrcar Cenifiulion Number
IS.OUTER CASING(for mehi-rausl wens)OR LINER Of 'cable)
IRON TO i DIsMr1TR THK1(NTSt MATTE14.1
SAEDACCO h. It. 1 is.
Compton Name IT..INNER CASING OR 11 BING t1rulbrrmal eWadase)r1
FRlril 10 III%%II It 14THICKNESS MANUAL2.Wdl Coestnsctior Permit M: '0 It. 18 (n. '2 it. I SCH-40 PVC
ha all applimbfe url',emiis tie.County.Aker,Variamre,Inie:O tt etc.) R.j ft. 1}II•—
in. jl
3.Well 1-v'chet'I:well use': Il.
11Atrr upph AA ell: PROM TO DIAMETER SI 01 Nlrr IUR 100 N. iverroAI.
--------- ------------
IIAgflculturAl OMuoicipal:Public 18 R 38 ft. 2 is 010 SCH-40 PVC
❑Geothermal IHeatingcooling Supply) °Residential Water Supply(single) R ft ran
I i tndustriatlCommercial ORest'detmal Water Supply(shared) Itl.GROAT
PROM TO + MATERIAL. _ 1 EMMA(IMENT METHOD A AMOUNT
❑Irrigation 0 ft. 14 ft. Portland Tremie
Non-Water Stfpftl%Well: R. ft.
RRlonitonng ❑Recover}' - — -
Injection Well: R. rt.
❑AquifcrRecharge ❑GroundwaterRemcdiaiion If.SAND/GRAVEL PACK(II appltca►k)
PROM TO MATRRIAI. PM►1AflMINTMF?HOD
❑Aquifer Storage and Rennes ❑Salinity"Barrier 16 R. 38 h. Sand 2
CI Aquifer Test ❑Stonmratcr Drainage
ft. ft.
°Experimental Technology ❑Sllhsidercc C'otarol Ie.DRILLING LOG tatted'additional Ards if arcessan)
❑Geothemal(Closed Loopi ❑Tracer PROM TO Di_5('RwwnoN'osier.I.nudity...rt&o.r1.ripe.rya*.s-.di.'
❑GeoHien al(Heating/Cooling Returns ❑Other(explain under rt21 Remits) n.
R. ft.
4.Date WiUt'1 Completed: 4-29-24 Well Ina Pz-s
O. It.
Sa.Well LA/CA ion:
ft. h. . .. •y....i +. i..,d
Toyota/Mega Site ft, ft
r
Factlrt-OoncrNane Fxllm !De iifapplicabk 2) ft. ft MAY O 2024
5938 Julian Airport Rd., Liberty, NC, 27298 ft j;
PIN seat Address_City-and Zip mam
ma MARKS - - . -n'
Randolph Bentonite seal from 14-16'
Could) .._ ._.. _ PrnelldcdiflcailonNo IPINI
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Ofwell field art lat-lottg Is srdlhtan 22.Certification: f,
N W AO J' 5/11/2024
Sigimsr:trr Cerlda."1 W'cll Contractor U :c
h.Is(are)the w rill s): ]SPennanrnt ur ❑Temlorran
$r signing Mu(tins.I hrrrM-certify that r1w walks ow torn.)rrnurna red is accordance
with 1 SA NCAC 02C,0100 or 15A NCAC MC,0200 Well Conatmdan Standards avid that n
7.1s this a repair to an existing well: JYes or ENO,t 4.01 of Jar,re,..J ha,Iran 1v.rrided t.+ihr srr11 n„crier.
Ifrbls it a repair,fill Isar knr.No„rig...n,rnnritm mfonwatnm aril r.giiai n the'furore of the
repair under t2f remark.an i,s'rt or.fin rho burnt of this form. 23.Site diagram or additional well details:
You nor; ,arc tit.back of this page to prosnde additional well site details or well
K.Member of wells eoratrTrctrd: 1 co(n(m.uun details. You may also attach additional pages if Iraessars.
For roahrple(sic"what or auvt-„rear ogtplr Wells ONLY with Ow time ranstrurraw ..a IYm
MIAOW.>ru fans. SUBMITTAL(NSTUCTIONS
9.Total well depth below lard surface. 38 Al 24a. For All Wills(: Subset this funs within 10 doss of completion of nell
Fur.r nhtplr 14v11,to,v0 Jr-rah+ifdrry.'..„ ;,.,,4to,pfe,10;00'rind is 1tHl' construction to the 101kmlrlg-
It).Static water level below toll rtr l'Asllr;:: 25 ((t,) Division of Water Resources,Information Processing Unit.
/r„air.inte1.,Oh....a.,:,; , 1617 Mail Service('eater,Raleigh,NC 27699-1617
I I.Borehole diameter:8•25" (in.) 24b.for Inection Well ONLY: hi addition to sending the form to the address in
24aabose. also submit a cops of this form within 10 doss of completion of well
12.Well roestnsctiun method: BSA construction to the following.
li.e.anger.rotary.cable.direct push etc.)
Dhision of Water Resources,Undergrrnrnd Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail scr s Ice Center.Raleigh.NC 2 7699-1h36
13A Yield 1 24e.For Water Supply &Injection Welk:
t7�) -— Method Also submit one Cop) of this form within iu des s of completion of
IJb.Disinfection h Amount: well constriction to the county health dcpannrcrtt of the cotmh w here
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constructed
Form GW-I North Camlrna Deport ent of Ern nmntitni aid Natural Resources-Ow eioo of Water Resources Rea red August 1'I