GW1--03716_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For Internal Use ONLY:
Tim form. of he used for single of miliipk a,ik
I.Well(unlrartur Information:
It WATER ZONES
Scott Hunt, Jr r11ON 1 It) , DC`('RlP11OI1
N'cll('onracu+r Narrk 5 ft. 11 ft, wet red brown silts
(I. It.
4561 I
NC Well Coiasacior Certification Number ; 15.OUTER CASING(for aobFtartad atilt.)OR LINER tita icahk)
PROM TO DIAMITTFR TNICKNESM I M TTRIAI
SAEDACCO h. i n. in.
Conytan�Name 1 I6.INNER CASING,OR TUBING(4e+lbenium'dne4-1M))
FROM TO DIVOT TES THICKNESS MATERIAL
2.Well Construction Permit d: , 0 n. 10 ft. 2 in. SCB-40 PVC
Liu ufl apphi a 1e ken permits(i.e.Countc.Stair,Variant...fi1'ecOal.t-.) — '
n- ft. is.
3.Well I se Icltrt•I:well uneM. 17.s(11EEt- -
Water Suppl Ndl: ►ROM TO DIAMETER a iii,iii I THI IOI1ts I MATERIAL
UAgrwultutal °Municipal/Public 10 R. 20 t1 2 in. 010 SCH-40 PVC
DGeothetmaldHeatin ooli Supply)y1 °Residential Waters (singlet R. fL in.
g,IC ng• i p>f. Supply(sin ct i
°Industrial Commercial °Residential Water Supply(shared) 'tarn", TO MATERIAL. EMPLACEMENT METHOD it ARGENT
❑Irngat inn 0 fL 6 ft. Portland Tremie
Non-Water Supply Well: ft. ft.
lEhlmtitonni; ❑Recovery
Injection Well: ti ft.
❑Aquifer Recharge Fifimundwatcr Rentediation etSANDIf'R. AVDLPACKOfatPlica01e► -
OAquifcr Storage and Recover [-Nation Barrier mom TO MATPRt\I. PMPi%(F\II xT NFSHOD
8 ft. 20 ft. Sand #2
❑Aquifer Test 0 Storms atcr Drainage
n. n.
°Expcnmcnial Technok gs ❑Subsidcncc Control
it.DRIILUNG LOG titled additional limits if meceasar,1
❑Geothennai i Closed Loop t ❑Tracer (ROM TO DisCRt►TYON i,slot.,llmane..,.Iia.,I 1s pt.wean.rr,rr,I '
❑Geotheual tlleatingtC•ooling Return, ❑Olhet(explain under ti2I Retnarksi 0 ft. 5 ft tan brown silt
rt
5 ft. 11 ft. wet red brown silt
4.Date Well(s)Completed: 5-30-24 Wtil ID.PZ-2E
11 R. 20 n, rock
Sa.Well Location: ft h. # •S
Toyota ft. R.
Facaiy.Clu erNome Foggia ID"(if atpplicabk► rt. rt. JUN ? 1 ZOZ4 t
5938 Julian Airport Rd., Liberty, NC, 27298 A. ft.
Physical tWtiess City.and Zip ICAO:l; f•a_?•^-Atilt:.1''JM4
21.REM kiks r•..
Randolph
Bentonite seal from 6-8' OVc' .r/\
I'cat k i I',ircel lden,dtcdion No 'PIN)
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certifications:
•al a,_11 Is-Id 'it.,oar Into r..idli.tull
: .•, r 6/3/2024
Sig: r.-Cdls1 .'ll Contractor t..,;
6.I+fare)the wellls): 70Permanent or riTempurar'' By.signing this fa,,,,I hereto certify rhea the wrll(r)was farce)cononnted in accordance
with l SA NCAC 02C.0/00 or 1 SA NCAC(2 C•OHM)Well Construction Standards and the,a
7.Is this a repair to an existing well: lVes or EN() ram ofthit eveoMhas been powided to the well owner,
If thus it IJ.rpcur•Jill tat;known a rtt.ro1.11wa son infotmarn..t urn!rcplaot the nature of the
reprirander 121 rentarko rrt-inm or on the bark of thin form. 23.Site diagram or additional well details:
You mat use the back of this page to pros ide additional well site details or well
8.Nosier et webs cDRstr.ded: 1 construction details. YOU may also attach additional pages if necessary.
Fur Inaltrple amjernan(o nail-water sir)tph wells ONLY wan Ow.ante construction sun,<tIm
sah,,uo<41r fon,' SI IBMITTAL INSTUCTIONS
<J. total Heil depth helms land surface 20 (ft.l 24a. For All Wells: Submit this form within MI days of completion of well
For nwhrple wells tut ail drpfhs tf dtgrrent'example-10200'and ZR/PIT) constriction to the rationing
-
10.Static water level below top of casing: 5 (ft.) Dtvisi)n of Water Resources,Information Processing t nit.
Ir.tm.J h'.-/t.,;1....,,,,t:r, ., - 1617 Mail Service Center,Rakigh,NC 27699-1617
I I.Borehole diameter:10.25^/6' tin.. 2411. Fur Injection W'eib ONLY: In addition to sending the fort to the address in
24aabose. also submit a copy of this form within 30 chins of completion of well
12.Well etsustrMYion method: HSA/Air Rotary cotistniction to the folknsing.
tic anger.reran.cable.direct push .
Phision of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ON I 1: 1636 Mail Sen ice Center.Raleigh.NC 27699-1636
13a Yield Itrpm► Method of test: 14e.For Water Supply A Injection'Wells:
Also submit one copy of this fonn mithui t(I days of completion of
I31i-Disinfection One: Amount: well constnidinn to the cotton department departmd of the county where
c:onstniclod
Forts GW-1 N+,nh(arobtia L)cpunnrta of Ern iroatninu and Natural Resources-Do aloe of Water R6otroes Res iced August loll