GW1--03012_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD For Internal Use°NL1'
Thus form can be usod for Stn{!k or elu.I' ,..'I,
1.Well Contractor Info nnatloll:
II.Witt ft 1.()N7.1
Scott Hunt, Jr r•ko I II) DE_M ItIPIllrei
41 ft, j ft. rock facture
4.561
lo. I` n.
15.OUTER CASING(for multi-cas
ed wells)OR LIN FR l i(ap arable
NC Well Contractor Certification Number )
PROM TO Dt1Mr7FR Tl cio,rss 1 MlrTI1tAL
SAEDACCO ft. ti. ia.
1
Caraway Name IS.INNER CASING OR TIMING I jealbersal soused-fund
PROM TO DLIMF TF N MRhsis. ll IIINI II
2.Well Comminution Permit 8: 0 ft. 25 ft. 2 111. SCH-40 PVC
Lot oil applicable well permits(Le.County.State Variance.II#Sellin elr.l - rn --- -
3.W'dl L,ic(cheep(well u'e I: 17 „
Water Supply well: PROM TO DISMV1PR SLOT st71 T1114104Vzor Si lrPRIM,
OAgncultural L(Munictpal•Public 25 ft. 45 IL2 is .010 SCtf-40 PVC
if N. in.
OGeothemialIHeatin Coolin Supply) I)Residennal Water StpP b(single)OInchistrialCommeretal I IRcsidenua$Water Supply(shoed) ir1lt.O CROUTM TO ,i‘I I NI NA. EMPUCEMENT METHOD t AMOUNT
❑IrnF:rtion 0 R. 20 ft. portland trimmy
Non-Water supph 1101: - — --,
R. It.
NMonitonnt ORecovery ,
!ejection Well: ft. R.
°Aquifer Recharge °Groundwater Rcmcdiation 19.SAN0+(:RAVEL PACE Of(poi RAW)
n1usI 10 `111 0111. ISIPLl1 FMr\T MrTnOn
❑Aquifer Storage and Recovery ❑Salinity Harrier 23 rt. 45 ft. sand 2
❑Aquifer Test ❑Stommsaucr Drainage rt. ft
❑Expcnmcntal Teehnologc ❑Subsidence('mum)
IA.DRILLING LOG IatlatS additional sheers it occessamI
❑Geothcmial(C'losed Loop i ❑Tracer PROM TO , Dec(-RIP rIu\1.nl.r.11.rd....,..,5nrko pt.grain'+to.ett.l
❑Gcodemlal(Heating/Cooling hewn') ❑Other(*.Nolan%under 1021 Remarks) 27 R. 45 fL rock
ft. ft.
4.Date Well(s)Completed: 4-30-24 W co ma PE-6
R. ft.
5a.Well Location: ft. it MAY 2 0 LGZ
Toyota/mega Site ft. ft. )
('.1•r(Gt1(r,.,.;t Nam, Facdm ID*,ifapplicable) `.. -.'. ft. ft. if.rv:::. - • .,
5938 Julian Airport Rd. , Liberty, NC, 27298 R R.
PlnsicalAddress.(-it. .ma Ty • '
21.RCMARICti
Randolph Bentonite seal from 20-23'
coma:. I'.u:.l I.k :a nnf. 6ua No API\I
Sb.Latitude and 1.onginuk in ire ,tes/minutes/seennds or decimal(Wolves: ,2.('ertification:
(ifwell field.rme lotior15 is stdlicknil
N W _�,� r� 5/11/2024
Sigi.0 Len siTc 'd1 Con Contactor Dam
6.h parr)the ssellls): %Permanent ur ❑Tempuras By signing this font,,!hereby certify that the wrl4ai taus turret ammo-led or mr'or,lanre
With/5A NCAC 02C,0100 or 15A NCAC 02C.0200 Will Carrtnk'nrn Sa,ndar,lu a,Nl dial e
7.Is this a repair to an cxisting well: °Yea or ENo copy of chit recant hat hero provided to the torll owner.
if this n o'epdr,rill curt k,,o,w Well,onAne lion l,forenornm and r%plain the nature of the
rrpuir under 021 remark..sr,hoer or an the ha't of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Nemberof wells comarncted• 1 COnSituctio 1 details. You may also attach additional pages if necessary.
For multiple*ilk*or Aral-Water,spph1.'ells ONLY with 01,woe c turria tins •...s<•on
submit one form. S UBMITTALINSTUCTIONS
9.Total well depth beltns land turfacc 45 (ft.) 24a. For MI Wells: Submit this font, %aphid 111 days of completion of well
For multiple Are.lone!!J.r'!..r.1:drroes fr'nrlpfe• (e'(ar and 2*/,oYI consimetion to the following.
la.Static water kid helow top of casing: 32 (ri.) Division of Water Resources,Information Processing l nit.
!Inviter letrl a oho.,,, •; '• 1617 Maid Service Center,Raleigh.NC 27671-1617
II.Borehole diameter:8.25"/4" tit.) 24b.For Inketloe Welts ONLY: In addition to sending the form to hit address in
24a abos e. also submit a copy of this form within t0 days of completion of well
12.Well construction method: BSA and air rotary coflalmctioul to the following
tic.auger.roan.cable.direct push ele.l
Dhision of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Series Center.Raleigh.NC 2i.99-1636
I3a Yield I1CPnn1 Method of tell: 24e.For Water SuP111s .Injection Wells:
— Also submit one cop` of this form within t0 day s of completion of
IJh.hi,inlct)inu(.pc: Amount: well construction to the county health dep3nrcnt of the counts where
COnstnlcled
Fore GW-1 Nonh Catalan DT:annrm of Ells non atni and Natural Resources-Disuba of Wale ROOMS Revised Algat 2011