GW1--04457_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD Ftirincnra!Use ONLY:
Thu Fortn can be used for single nr mi.liipk orals
1.Well Contractor Information:
II.WATER ZONIS
Tyler Brown VIO)SI I TO DFtt•RIPI1ON
Well Contractor Nara: ft, R.
4625A n. n,
NC Well Contractor Unification Number 11,0[1TRR CASING(tr►eRMI er+evl oast OR LINER iif ape kaki
FROM TO DRSMrTFra T►sicaNTss N ATV NISI
SAEDACCO 0 n. 50 n. 2 ia. SCH-40 PVC
Coil un Nang 1s.INNER CASING OR T V LING(geothermal cfrare441s))
FROM TO DIAMETER TNWKNEa9 MATERIAL
2.Well Construction Penult N: R. ft RA
Ilse all apphk able well permits(Le.County.Slane,Variance.Itteetfat rle.) n J
3.Well Cac!check well use): 17 SCREEN
Water Supply Well: !ROM TO oissirr-R a of iorr TMt(TNSt s ; MATORIM.
50 ft. 60 ft. 2 in, 010 SCH-40 i PVC
LI Agricultural OMunicipalPublic •_
OGeothemlal(Heating)Cooling Supply) OResidcntwl WaterSupph lsingle) K' K in'
OlndustriatCommercial I!Residential Water Supply tslraredl lit G/113
/IrDM TO MhTERLi1. —7 EMPLACEMENT METHOD aAMOUNT
[limp:titon 0 ft. 46 ft. Portland Tremie
Non-Water Supply Well:
R. n.
RMonitonne ❑Rctoccry
Injection Well: ft. rt.
CI Aquifer Recharge OGroundw:aterReniedi:pion 19.SAND/GRAVEL PACK(Iftn1calle)
El Aquifer Stange and Rccoscn ❑Salinity Barrier not to seATPRl0I. F:NPt.rf SITNT MFYFtnn
48 ft. 61 ft. Gravel pack #2
❑Aquifer Test ❑Stomm:eer Drainage
ft ft
❑Fspcnmental Technologs ❑Subsidcncc Control
20.DRILLING LOG Must*dal sheets Wo,c rsI
❑Geothermal(Closed Loop i ❑Tracer FROM TO DESCRIPTION fr,.l.r.►near..,..a.nn t IK.%r,m r...nr.i
❑Geotheal(Heating/Cooling Return! ❑Chtrer(explain under 021 Retnails) K K rm
ft. ft.
4.Date Well(al Compkled: 6-11-24 Wen 1DMPz-17R __
R. rt. r
Si.Well Creation: ft. l n. ..II., ./ -
Chernours rt. O. -- U(. 3 rn 2n24
Facilii P Name
et rNae Foam IDS ,f.pptr:aMel J
rr, (I.
22828 NC HWY 87, Fayetteville, NC, 28306 H n ft If.iafllti;;C,• ,t unit
Phi,weal.Address Cin.and Zip r 'f ._ "•+�iZ
2l.RLMARKS
Cumberland Bentonite seal 46'-48'
4,r,n.r. Panel Lk al.mcalinn N.. ;MI
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,(erlifkation:
of ec11 rein one telong is wflicieisi f
N W
,� /✓---2_____..-__ 6/12/2024
Sigimai.of Certified Well Contractor Doe
6.Is rare)the Nelbs): xiPermanent or ❑Tentporar In regnmp gar Mtn, I hereby Certify that thr wYlpsl will twirl ew.rlrn-ted in accordance
.roll I SA NCAC 02C.0/00 or I sA NCAC(CC.0200 Well Co.touwenem Standar*s and that a
7.Is this a repair to an euistiog well: DYes or RN* a.ipr Of MAT record has hrrrl prarukd S.tSN..ell en.mrr.
lfrbo to a repair.fill uwr known well,.aurrm roe mform.nue and r%plain Ow waste 4 rhr
repair under 021 reeiarkr.rri leort or an the bank of thus form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of welb eorm..ted: 1 construction details. You ins also attach additional pages if riecessan.
For arahride miecrlort or,IOn-eoirer sapyrh wells ONLY wall else snare cmratracaioR tea.or
,:a„n,I,.,1,(,,,,.., SUBMITTAL INSTUCTIONS
'1. total well depth be4m land surface: 61 ((t,) 24a. For AU Wells: Submit this litmi within VI days of completion of well
for maheph weds lot all ekyrhs ifd,Iferrnr teranupie-.tea,201?'aryl?f�1071 constriction to the following
18.Static water level below top of casing: dt.1 Diiisian of Water Resources.Information Processing I.nit.
If nc.:r,lr.rl n ohm•assay.a.r 4. 1617 Mail Service('cater.Raleigh,NC 27697-1617
II.Borehole diameter:6" (in.) 21b.For!niceties With ONLY: In addition to sending the form to the address in
24a abase. also submit a copy of this form within k)days of completion of cell
12.Well coeatroction method:Rote-sonic construction to the following.
4I e.auger.roan.cable.direct posts Mc.)
Division of Water Resources.Underground Injection Control Pru -am.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Seri-lee Center.Raleigh.NC 27699-1636
13a Yield 24e.For Water Supply A Injection Wells:
IRPo) McHtsd ref lest:- - Also submit one cops of this Conn is Ohio ;it this s of completion of
1311.Disinfection type: Amount: well constmction to the counts health deportment of the count where
constructed
Form GW-I tint Carolina Il punment of Em mutton mid Natural Resources-Dwaloaof WokI Retiree /to used.August'v:I