HomeMy WebLinkAboutGW1--04496_Well Construction - GW1_20240730 i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
The forth can be used for single or mullipk hells
I.Well Contractor Information:
PR Tyler Brown PROM � � D►1Crttai1014
Wc1I CoCrtclta Nine R. ft,
ft, n,
4625A
NC Well Cararactor Ccnifratton Nunbcr 15.OUTER CASING(fur rwisi-caul erIls1 OR LINER Il(O!pneabk)
_yRON TO DI,\1rTFR _ THI('ANrSS N{TT RI Al
SAEDACCO 0 fi. 22.5 n. 6.25 iu. SCH-40 PVC
(r,1,g,;i„i N.ic„c IS.INNER CASING OR T1 81N(:Ilrutkuraal ch,srd-loop)
fpll.l - 10 , 1,I\NiIt11 III))h.INS MATERIAL
2,Well('onstrvetimr Permit k: 0 fi. 51 ft. .2 ins. SCH-40 PVC
List all applicable well pe mu.fie.County.State.t'tria,e r.IIYe earl elr.l •
r
R. 1 fi. �_--iw
3.Well Ise(check well oxen O.SCRLIEN
TROIA TO nl%ItFF R MOT SITS THt(T(NR9S MATERIAL.
Water Supply Well: .) -_ -
LIAgriculturtl OMunicipal.Ttblic 51 R. 61 ft. 2 .n 010 SCB-40 PVC
I Geothermal(Beating/Cooling Supply') OResidential Water Supply(singlet
R. R. ia,
I I IndustrialiConitlercial OResidentud Water Supply(shared) IL OtO11T
FNOM TO MATERIAL IIMMwCT?:MTINT Nil.111(w a AMOUNT
❑Irrigation 0 ft. 22.5 ft. Portland Tremie
Non-Water Supply Well: 0 ft. 47 ft. Portland •Tremie
®Mouitonni; ❑Rccovcty
Injection Well: ft. ft.
IA Aquifer Recharge ❑Cjmundwatcr Rcmcdiation It SAND GRAVIL PACE(if apwoille)
❑Aquifer Storage and Recovery ❑5 rlirtih Barrieri FROM TO M ATRIUM,, F Nri.A(-rttl'UST%IFTHOn
49 R. 62 fc, Gravel pack #2
❑Aquifer Test ❑Slomntatcr Drainage
ft. ft.
❑E:q,enmcntal Technoloin OSuhsidence Comm!
2o.DRII.I l'tG LOG Iatttach additional skeet.if necessary l
❑Geodicmal(Closet!Loup) ❑Tracer caosl 10 1 orsca Ptlfl roles.htrdnr...,oLL,,ai.fl pr.ffau.Ale.0,1
❑Geothemal lHeatnrgtC•uulmlc Return) ❑Other iexplain under 021 Remarks) O. R'ft. f
Well(s) . j ft. . +/
i.Date rll(sl Completed: 6-20-24 M.cal!Da PZ-25 RR n. fl.
5a.Well Location: ti. . R. ,'UL 3 11 2n?4
Chamours ft. rt. �J l(
Fecility,'Ot ncr Name Facility(DM of applicable', ft. • e. Iri(d:1:i%.t._.: r r.arc -,/.UR*
22828 NC HWY 87, Fayetteville, NC, 28306 ft. ft.
Plnsicai Address.Cott.and Zip ' 21.REMARKS
Cumberland Bentonite seal 47'-49'
hutch ldeiutifue.:annt N.. IPI\,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ,2.(crtificatioa:
Orwell held.one I:u1iur,it sidl',cicirl
N W nu �'f�` 6/20/2024
Sig ofCentfcd Yid Comoetor Dose
6.Is tare)the Ncllts): %IPennanent or DTeetpsrary H.signing MO lumr.I herrb,•certip•than rile wr*Hxt oat iorrrl tomrfnrrrert in accordance
with I t4 NCAC 02C.0100 or 15.4 NCAC 172C 0200 Well C(n stria n(at Standards and that o
7.is this a repair to an existing well: Data or 19 No .•pr airfoil record has harm provided-the well owner.
If Chit is a rrpur•em!!tot known w ell marina lion infarnwtrirat and r.spiain the nitrate of rile
repair under.121 rrinartr.section or on the bark of this fors,. 23.Site diagram or additional well details:
'You ma, use the back of this page to provide additional well site details or well
8.Number of wells coratar.eted: 1 construction details. You may also attach additional pages if tlecessan.
For niilhtple hnfecrhm tie tiotl-wYirtr iamb wails ONLY ism the MIN roaatreednr.sou trin
submit one Jnn.r. SUBMITTAI JNSTUCTIONS
9.Total well depth below lard surface: 62 - (n.l 21a. For All Wells: Submit this form within 30 days of completion of well
For.nibiplr welts list all depths if deferent tr.ran pk.3D21MY and 21Q lllp•1 construction to the follow-Me
18.Static water keel helms lop of casing: ((y,l Division of Water Resources,Information Processing Unit
If wane,lr.n r. ,I.,r,-,uiii't n•< - 1617 Mail Service('enter,Raleigh,NC 27699-1617
II.Borehole diameter:6" (is) 24b.for Injection Welb ONLY: In addition to sending the form to the address in
24a al o e. also submit a copy of this form within 30 days of completion of well
12.Well cottalrvetinn method:Roth-sonic cousiructiun to the following.
tie.anger.retsn.cable.direr push crc i
Dhislon of Water Resources.llmlerar,sund Injection C'untrol Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 2"694i-163(.
•IJa Vivid IL'Pml Vcdunl of rest: 2k.Frei%Cater Nuppl, A.Injection Wells:
Also submit one cop, of this funs within tU day s of completion of
Ult.Disinfection n pe: amount well construction to the county health department of the count where
cossinicled
F,,,t•t t:'r1-I Noah Calcium 1).sottnlem of Em tionunriu and Natural Resources-Damao of Water Rnotwals Re.tsed August 2613