GW1--04456_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD For totems'Use ONLY:
This Form can M tls.,d for cinpk or midi'plc ndlc
I.Will Contractor Information:
II WATER ZONES
Tyler Brown i FROM TO DVST111PTiI)
•d,:I1 i.irractM Name ft. fL
4625A
f6 I f6
N( Well Connector Cenifteai ion Nanber : I .OUTER CASING(fur multi-eased welts)OR LINER tit ap tkabkl
'MOM ! TO Dta WIT R TIT I('KxVN5 MATERIAL
SAEDACCO 0 ft. 15 ft. 2 it. SCH-40 PVC
Compaq Name j Ie.INNER CASING_ OR TURING111104 ,w Idprud.batl
FROM I TO DIAMETER TRICTCNLRE OIAIUtWL
2.Well Coaatruetirnt Permit ii: _ ft, ft. in.
List all applicable Nell permits(i.e.County.State,Variance.spathes ea-.! - -fie. tie no.
3.Well Use(cheek well uses: 17.$('Rt[M
Water Supph Well: WROM TO Dt4MWTPR MtOTS= 1111CKNICIS MATRRtAI.
UAgnzultural °Municipal.Pl)Ilc 5 R. 25 R. 2 is 010 SCH-40 PVC
°Geothermal Meeting/Coolingfie fie
Supply) ORasidcnta�l Water (sir>Kde)
O hrdusltial/Coninscrcial ORcsidcnn l Water Sttpph'shared/ IL(JRODT
IrROM TO _ MATERIAL EMP AtiM6VT INEtR00 a AMOUNT
0ingtiion 0 ft. 1 R. Portland Pour
Nan-Water Supply Well:
RMonitonne ❑Rccoa'cns
Injection Well: R. It
❑Aquifer Recharge OCimundwatcr Remcdiation 19.EANBlGRAVRL PACK OfapgMeaMe)
WROM TO M4TVRtat. - 'NM Ai TWAT Mr.TIM0
°Aquifer Storage and Recovery' ❑Salinity Ramer 3 R. 26 ft. Gravel pack 12
°Aquifer Test ❑Stomns.itcr Drainage fie• R.
❑Escpcnnicnial Tozhnolop ❑Sohsudcrsx('otiml
} It DRILLING LOG(a11KI additional Owns if acceasan)
DGeoihennal(Closed Loup t ❑Tracer Wine TO - DESCRIPTION tuaor.r.rr,o.....ai uk nst.vies*We.du)
°Gcotleennal tUeating.'C•uoling Retuntt °Other(explain under/1'1 Renwdsi R. ft.
ft. II.
4.Date V1'el1(11 Completed: 6-13-24 Well ID.INSTTU-02R
R. fL
Si.Well Location: ft. R, ' ` �-. `.,a.. , 1,' ._Li
Chemoara R. a J U L 3 0 2024
Facie Oa ner Name Vieille IDO(if applicabkt A. IL
22828 NC HWY 87, Fayetteville, NC, 28306 sat..r.ww.,..lal •. ..was. ..I Ur*
Plnstcal,Address.City.and Zip r1'hC , 1"'
21.Rim
Cumberland Bentonite seal 1'-3'
,..a r. Prncl W.:M :Aiotw Na 1PP41
Sb.Latitude and I.ungitwk in degr•e.:nunun's'sccnnda nr decimal degrees: 22.Certificatloa•
or sell field.ne I:Wluig is sarl't:teot
N R �� / �� 6/14/2024
Sigma.of Certified Wdt Contactor Dote
6.Is 1arN)the wellls): x Pennanant or I rnrlerrara th signing dos lacer.I hereby terrify chat the uw*al awe farts,anarnnn,ed it,ocean/our
with 1(4 NC.4C 02C.171010 or 14 NCAC 02C.0200 WeU Ca,Wrwcion Satalirdt and rho(a
7.Is this a repair to an existing n ell: J It ea or X.NO .-err o(the record ha.horn ptnrsLd to the went owner.
Ifant is a repine,full unit 4171,111.1 a ell.eaet,lft near tnfort,watotu and r'pawn,hr wane of tie
repair ender 121 rewwrks.roc ircm or on the hock of this form. 23.Site diagram or additional well details:
You may use the bock of this pace to pro'.ide:dditional well site details or well
8.Number of well conerlructed: 1 construction details. You Ina%also attach additional pages if tucessan
For maniple injection or non-staet woo,.a.11,OM .urn n rhu atone ensS va rior oil c of.
.
sah,.t,l :.�; +,r,.• SLIlh11TTAL INSTUCTIONS
9.Total wsii depth below land surface: 26 (fl.) 24a. Ear All Wills: Submit this yore within III loss of completion of well
for mainplr Wells lot all d, .'dttlrre'a' . ........ ."a'rat road'..toil) construction to the tenoning
IR.Static water level below top of caster iry.i Division of Water Resources,Information Promising Unit.
it noir,ie.rl n.thorr 1 usa+y ace '+ 1617 Mail Strike('cater,Raleigh,N('27699-1617
i I.I3orekok diameter:6" (in-) 24b.For Inketion Wells ONLY: hi addition to sending the form to the address in
''laabcne. also submit a cops of this form within ;(t days of completion of well
12.Well coaatneetion nwilied:Roto-sonic construction to the following.
'i e.auger.roan,cable.direct push et.,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONI ': 1636 Mail Sell ice(crater,Raleigh.NC 2'ft 9-►h36
13a Yield IApml �Icthml of test_ 2 lee.For Rater Suppls &Injection Wells:
Also submit one cops of this funs within 10 etas s of-completion of
I3b.Disinfection type: \mount: well constniction to the count} health department of the cotton w here
constructed
Form GW-I Nonh Cantina Dcpunnrtu of Fun uowrtcnt and Natural Resources-Division of Waicr Resotrm, Res tied August 1,1;