GW1--03726_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For Intermit Use ONLY:
This form can be used for singk or multiple cells
1.Well Contractor Information:
14.9YA1R�Wti
Scott Hunt, Jr PROM TO DtSCRIPT1ON
Via Contractor ham.: 25 ft. ft. rock facture
4561 n. ! ft•
NC Well Contractor Cenificatbn Number 15,OUTER CASING(for an lti-casrdoeNsl OR LINER III applicable)
FROM TO nttMITFR THI(TC\Esti M111141%1
SAEDACCO h. ft. in.
Company Name 14.INNER CASING OR TURING I)pesdonsal clued-hrukj
PROM TO DIAMETER THICKNESS M.%TT R1.11. --��
2.Well Coastnictioa Permit#: 0 ft. 14 ft. 2 v SCH-40 PVC
List all applicable well permits lie.County.Sane.Variance.lrge best rn:J .,
R. R. iia.
3.Well I:se(cheek well use) ,
19.8(RttN
Water Supply Well: PROM TO sIAMPTIle slot sirs I TH RN P.N t(T(N % 1 MATI4I.
UAgncultural I_IMunicipal;Public 14 R. 34 R 2 i+• 010 SCH-40 PVC
O nt Geotheral((Heating/Cooling Supply) I.)Residential Water Supply(single) R. R. in.
Ohldustrial/Commercial I(Residential Water Supph 'share:d) lt► OJT
IBOr7M TO M%Tr.M M. EMPLACEMENT METHOD&AMOUNT
Olmgation 0 ft. 10 ft. Portland Tremie
you-Water Supplt'.%ctl: .--..
rl. R.
®Monitonnc °Riscoy.n
Injection Well: n. n.
❑Aquifer Recharge i_ltirotind ;uer I(s:nas:dimion Iv.S.tND.1.R.ft.ctt.P%CKalEllidei
thins I., M,►TR t31 6:MPI..4(4:m1rT1418YM1
❑Aquifer Storage and Recover) ❑Salinity Harrier 12 ft. 34 Cl. Sand #2
❑Aquifer Test ❑Stommatcr Drainage
R. ft•
OExpenmenlal Technology' ❑Subsidence Coilml
IS.11)SOd(NG LOG iattach addilirnal shorts if 16aesssanl
OGeothenml(Closed Loop( ❑Tracer ►Rost To ._DP:f R:PI ION,tutor,h..dily..,..,unal.1pc.V-.is+ra.(*.)
OGeothertnal{Heating:Cooling Return) °Other(explain under 1121 Rem ota) h. ft.
0 ft. 15 ft. tan pwr
4.Date Well(s)Completed: 5-30-24 Well IDNPZ-1E
15 R 34 h rock . .
5a.Well Location: R. R. �',*�/ 1A1I ki ��
Toyota ft. ft. JUN t 1 2024
F:k'Ivey Oss ncr Nan.: Facility lDN(if appliutblcl
5938 Julian Airport Rd. , Liberty, NC, 27298 R. R. If,119;.+swfC1
Musical Address-Cin.and Zip ���Vo
21.REMARKS
Randolph Bentonite seal from 10-12'
Cry Pareclldcnlif.caionNo (PIN I
5b.Latitude and Longitude in d(.recsiminutes/sccnnds or decimal degrees: 22.certification:
;,1 c,,,L 1%.•I,l n,t lit long c..rrlllcwut'.
N W' di(,,,,,,,f---,4 ---. _ 6/3/2024
cigr :e.Cen Cm oac6or Date
6.to(are)the well(s): XPennanent or :Temporary
By signing this forts I hereby certify raw the we1Ns.was(beret comma-led in accordance
with ISA NCAC O2C.0100 or 15.4 NCAC MC.0200 Weil Construction Standards and chat a
7.Is this a repair to an existing well: :t es or IL Nu raps of this record has been provided rn tar evil meter.
If this is a te)wtr,fill 401 ki,.wo writ,<wu/44 Jun,n,jrn.,golo.,aaJ rxplahl the nnrrre of the
repair under121 rrmarks.rr.9ran or on rhr hack of this form. 23.She diagram OE additional well details:
You may use the b;,.1,of this page to pros tde additional well site details or well
S.Number of Hells eoustr i i.-ted: 1 construction detarb. You may also attach addtnaal pages if necessary.
Ion multiple a iesta;n to auvn-wafer strppl,wells ONLY,,,rh rI,r same construction vow can
submit one forte. StIBMITTAL INSTUCTIONS
9.Total well depth below had sttrface 34 fry,) 24a. For Al Welly Submit this form within 10 days of completion of nett
For mat 1ple wells list all depths if different terampfe-Q 200'and 2@ ion corlstnirtian to the following
II.Static water level below hop of casing: 20 (ft.) Division of Water Res(turres,Information Processing Unit.
Ifeasee ie.0 V.,rh..rr,a;v,z ,,.,• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole d ameter:10.25"/6' ,i u., 24b.Far Inicedoe Welly ONLY: In addition to sending the form to the address in
24aabove. also submit a copy of this form within 30 days of completion of well
12.Well cousirwetion method:RSA/Air Rotary constntction to the following.
tic.auger.rotary.cable.dirt push.der
Division of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen ice Center.Raleigh.NC'27699-1636
24c.For Vt aster Suppis B.Injection Wells:
13.1.Field(gpm i birdied of seat:--____-
Also submit one copy of this form 1lithml 30 days of completion of
13b.Disinfection type: Amount: well construction to the count health department of the county where
constructed
Form GW-1 Noah Caroluia Dgienmem of Sirs(mlwau and Natural Resources-Dn 15,Ion of Water Resotsr m Re,wed.August to I?