GW1--03830_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD c6 F.,.l,trr„a:I ON!S
This form can he mod for single or rethink netts \��
I.Well Contractor Information: \
111 11.WATER ZONES
Rich Lemi re FROM To j RIM-MP'ON
Well Contrdelor Name ft. ft,
2593A e. ft. i
NC Well Contrac(orCcnifcalnon Number 115.OUTIR CAMNG(far multi-eased wells)OR LINER N LINEf applicable)
PROM Ti) T)RWFTFR 7 TRRK 5' M%TERRAI
SAEDACCO h. It. na. 1
• Iw.INFER('AslNT.OR71'81NG( ivnh•rtaddnad-Ion - ~
(7wttphu.Name P P1-_.
a R.NI II.) 111\\1111N 1111t ntyrs� \I\11 RI tl
SCH-40 PVC 2.Wdl Construction Permit M: 0 n. 6 n. �2^ in.
Lilt all applh able well permits its tie.Covwv..Shaw•.Variance.GtKPJOt rte.) - LT } --------
ft. I fl. 1 en.
.3.Welt I se ii iw.I.we'll nisei! 11.5('REIN
f
Rater Supply Vs ell: PROM I n0 DIAMETER '.Ifni MUTNK1tvI.• M\t 1 NI%I.
I.IAgrtcult111:I1 IIT%1wlicgnlll�Itblic 6 R. 16 R. 2" iR .010 SCH-40 PVC
I lGeothemal IHeating.Cooling'St q,plk 1 ;kesidentgl Wafer Supply(single) ft' R ~
IbtdustrialiCommercial t Resider Water Supply(shared) ILGS°, T
FROM TO MATERIAL EMPLACEMENT 7/1111104t A AMOI:NT
❑Ingaiion 0 ft. 3 ft. PORTLAND POURED
Non-Water Itpply Rill: R. It.
R Monitonne ORxmrn' _
Injection Well: h. n.
ElAquifcrRech.-u nt Recharge ❑GroundwaterRccdianion I9.SANDM.RA\'EL PACK iirattptkablci --~
OWN TO SI11RRI\I _ WWII.N(EOt%TMI-TiIOI
°Aquifer Storage and Recovery OS:dinky Barrier 4 ft. 16 ft, SAND 12
❑Aquifer Test OStomns:ecr Drainage
ft. ft,
❑E'pcnnicntal Tcs:hnolog\- ❑Sabsidcncc('meml
a.DRILLING LOG iillach additional dNre1\if accessary I
❑Geodrcnnal iClosed Loup' ❑Tracer PROM TO DIS atPDDON 1,,.6r.Aardsr...will,.L hpr.►eon wit.,ch.l
❑Geuthtta e( l(Heating CooliRennin ❑g Rennin (explain under 021 Rei anla) 0 R. 6 ft RIVER SAND
6 ft. 8 rt. ROCK
4.Date Wellpl Completed: 5-13-2024 Wd 1IDAt-1
8 n. 20 R, IN AND OUT OF ROCK AND RIVER SAND.
5a.Well Larcatklc
Shell It. II~ .\i...(,, "h•'
Facuh Onrte, rmune Facdiq IDktifapplicabkl % l�
ft, fl.
2760 Stewart Rd., ANDREWS, NC, rt. fl.' IVN 3 8 2024
Plnsocal Adbess,City.and Zip `21.RLM,,RAN illift9fniif f t Aar
BENTONITE FROM 3' TO 4'. O� .T
CHEROKEE DV.Q/306
Coma. Puss)kkm,fw:_,ion No IPIN,
Sb.Latitude and I.nnginuk in degreesim7Rnteshcrnnds or decimal degrees: 22.CerNtratinr
Wool'field.ne,Ian I,ati r.„dlicitatl
-S
N W _4i1+nv..t� 5/14/2024
Si',oI,t of Cat Weil Contractor Dale
6.Is are the c ell(sl: X Permanent or ❑Temluran fis Ammo:ills Jane,1 henrbe certify that the welds,tour(nerd corrrino-red is acrordartte
with 15A NCAC OZC.0100 or 15A NCAC 02C.0200 Well CaWnN'tioe Standards and that n
7.Ls this a repair to an existing well: _;'S es or KNo ripe nfrhit reranf hat hero pravid d rn:he%tell nwaer
if thb u a repute,tilt Ana tm..wn w,It(.Noma inn rafarmwrwm.a+tr a%p&,o,the Name„f rhr
repair under I?l remark.,se.tiaa ar on the hall,if this form. 23.She diagram or additional well details:
You may use the buck of this page to provide additional well sue details or cell
S.Neasber of wells coo trueted: 1 con slnh.tion details. You ma\also attach additional pages if IILVessan-
to,muInple mjettown tor rhmt-wafer lappl.went ONLY watt the some co nfrw•Narr sup Ilia
tdfmnd'ow loon. St!Shill-1A1.INSTUCTIONS
9.Total well depth below lama surface 16 (ry,) 24a. Ear AU Wells: Submit this limo within 1t1 days of completion of well
For mina*wells hit all depth,nfdrferrnt lr-unnpfe-145'2ft>'and 1F(Off) construction to the following
1..Static water les el hcluw top of railer 8 (ft.I Division of Water Resources,Information Processing(nit,
41,1110 irtrl h ohm r,.1•,.,. - 1617 Mail Service('cater,Raleigh,N(-27699-1617
I I.Borehole diameter:8.25" (fa.► 2lb.for Injietloi Wells ONLY: In addition to sending the form to the address in
24a abuse. also submit a copy of this form onion r()days of completion of well
I!.Nell construction method:AUGER/AIR construction to the following.
u e.auger.roan.cable,dime,punt%etc I
hisisinn of Water Resources.Uedcrgr d Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sers ice(enter.Raklgh.N( 2 7699-1 636
!Tit.1 ihid iepnnl \Irmhnd of test: lie.For W.alt•r Nupph X Injection Wells:
Also submit one .op% of this tour it Edon '., da%s of coo plciion of
131,.Disinfection ty lie: Amount well construction
to the county health department of the county is here
constnncied
Form GW-I Non),('arollwa tk sinnrw of Ern ttotunetu and Natural Resources-Disabo of Water Resarces Re,sad.Aigust 21111