GW1--03725_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD ��'\I FallacrnalltxONiti'
m The((WRIGHT be used for sink or rnnitirk..cgs \
I.Well Contractor Information:
It WATRR ZONIS
Scott Hunt, Jr PIIOM TO nr S4 RIP IIt IN
WellC'orrrtcu r Kink 30 ft, ft. rock facture
ft. II,
4561
NC Well Contractor Ccnifaalion Number15.OUTER CASING(for shall i-cutril welts)OR LINER tit applicable)
Most To nrrsrrrrit TrtictorNs , sl;iTNW
SAEDACCO ft. (I. ia.
Conmpm)Name 16.INNER CASING OR T LBING trualherusal closed-loop)
FROM TO DLAMETER rtIKC k\E.S MATIRI.(I_
2.Well('onstruction Permit#: 0 R. 20 fi. i 2 la- SCH-40 PVC
1.L0 tall applicable well prrmair(i.e.Cowie.Maw.Variance,Itch fie etc.i 1
f. ft. 1 in.
3.Well Use(check well laser — -
17.S('RItN
Warr�pl Well: MOM TO DIAMITFR I mot sin TN1(1tt41tS% 1 MATFNIAI.
❑AgtlCulturaal OMlmicipabPubluc 20 ft. 40 ft. 2 i.• 010 SCH-40 1 PVC
71
OGeotheal(Beating/Cooling Supply) OResidential Water Supply(single) ft n its
nn ,
❑hdustriaUContmercial OResidemial Water Supph,shared) 11, OUT
FROM 70 MATERL(I. EMPLACEMENT METHOD i.AMOUNT
El Irrigation 0 ft. 15 ft. Portland Trestle
Non-Water Supply Well:
ft. n.
R hlonrtonn►; D Rccoc en _
infection Well: rt. ft.
0Aquifer Recharge ClCiroundwaler Rcnicdiation 19 ILISNI iGRAVEL PACK air ap}YeaMe)
OAg1lifCf Storage and RccnAcn ❑lahnlft Barrier
F1QM TO so ATFRtSI. rMPI.a1 ENIENT*Irmo
18 ft. 40 ft. Sand #2
['Aquifer Test DSlommater Drainage ft. . ft.
❑Experimental Tee hooks*. DSubsrderkc Control i
2•.DRILUNG LOG l h additional sheets if uucenan 1
OGeotltcnnal(Closed Loop) El-Tracer FROM TO DirsCRtPTION,<sl•r,harms«,q.a'nnl.Npt.eraia.ips,dr.)
OGeothettnal(Heating Cooling Return) DOther texplam under 1r.1 Reitutr►sl 0 ft 15 tl tan silt
15 fl. 35 ft, tan pier
4.Date Well(s)Completed: 5-29-24 Weil iDMPZ-4E 35 it 40 ft, rock
5a.Well Location: ft. ft. t'• I .• • 4!1 ."-,
Toyota ft. ft,
+�`I f` icy/q i.
Fanlni OwnetName Faciliy ID#(if applicabk) R. JUN 9 I 20L4
5938 Julian Airport Rd., Liberty, NC, 27298 rt. It.
Y
Plnsical Addncss Ci[,-and zip Irkx.:4,,i rA N "+I..,' %
2l.REMARKS o-f,-;'a'il._:,t
Randolph Bentonite seal from 15-18'
Cowl) 1 awei Identification No IPIN1
Sb.Latitude and Longitude in de a'ers/minutes/seconds nr decimal degrees:
of well field.um lat.luug is sidlictem l 22.Certification:
N W 6/3/2024
Sig11.014frie
r.CC1110 Wdl Conmctot [hoc
6.(s tare)the wrllls): ZiPermanent or :JTemporal-)
Bs signing this fonts./hereby certify that the weeks)was(nrrrl corn/Mini in a.cr ordaracr
with 15A NCAC 02C.0100 Of 154 NCAC OW.0200 Well Coustn..tirw Standards wet that a
7.Is this a repair to an existing well: :Li Yes or g No copy of this errant has been pr»rided to for well owner.
if this as a repair,fill mai 074M l w elf.iota Ho l,,o ml,.re$eriw,:ion!r yeast;Mr manor at the
repair under 1,21 remarks se,ion or on the hail at chit farm. 23.Site diagram or additional well details:
You Mai use the baci,of this page to provide additional well site details or well
8.Number of wells oauslneted: 1 construction details. You 111as also attach additional pages if liecessan.
For malrlpre injection IN eo.i-NYIR'r aseppli wells ONLY non fhr same construction .."a<<,n
.seitrmitone/aria. SiIBMiTTAL iNSTI1C11ONS
9.Total well depth below land surface 40 (f1,1 24a. For AN Welk: Submit this form within ?U dues of completion of well
For multiple cells has at depths it diti'rent frra4apte-30100'and 2f1'noon) conntnrction to the following-
M.Static water lesel below top of casing: 20 (ft.) Division of Water Resources,laformation Processing l nit.
.. ... : ,r , ., . ,. .., ,.. . 1617 Mail Service Center,Raleigh.NC 27699-1617
I I.Borehole diameter:10.25"/6" tin-) 2lb.For lnketioe Welk ONLY: in addition to sending the form to the address in
24a abose. also submit a cops of this form within 30 days of completion of well
12.well Wuslructiun awthm1: HSA/Air Rotary constnaction to the following.
tie.auger.total.cab', 'U*,c,I' '
Division of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scr.ice(enter.Raleigh.NC 27699-1636
13a Yield Omni) Method tat test: 24c.For IA Ater Supple &Injection Wells:
Also submit one cops of this form within sti dass of completion of
13b.Disinfection O pr. Amount well constmction to the count} health department of the cnrtn1A where
---. constructed
Form GW-I Noah Canhrn Depannrnn of Em rloannCnu and Natural Resources-Des man of Water Roams Resod August 2013