GW1--04543_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For irrcrnnllrsrONLS':
The form can Iv u•.:d for sink or mulupk sells
1.Weil Contractor Information:
II,WATRR ZONES
Tyler Brown PROM To DESCRIPTION
Writ f'onractor Naas ft. ft,
4625A n' ft'
NC WO CommctorCenificatan hunter 115.OUTER CASING(far meltieaurd wells)OR LINER(ifapplicable)
i FRON TO Dt;M►1TR Tni('A\'ass NsTTHtsI
SAEDACCO 0 It. 18 ft. 2 is. SCH-40 Pvc
('onr:un N. lb.INNKR CASING OR TUBING( ealberatal cIne44uop)_
PROM TO • DIU IFTF:R _ TIII('ANF5' MATERIAL
2.Well Construction Permit N: ft. ft. in.
list WI appli.able tall prrm.tr(cr.County.Use.Variaure.Inject o4 rtr.) ft ft is.
3.3.Well Use(check well owl: 17
SCRIM
Water Supply Weil: ROM TO Dt5MWTr.R _st tit sin TNt(T(nksl • MATTtrtAt.
LIAgncuttural DMunicipal/Pitbhc 18 h. 33 ft. 2 ixO10 SCH-40 Pvc
LIGeothermal(Heating+Cooling Suppty) OResidenttal Water Supply(single) R ft. is
I lnduslrial.'Comnicrcial OResidcnnal Water Supply(shined) la GBOV1
ROM TO MATFRIAt. EMFI_(CFMENT METHOD t AMOUNT
❑lmgauan 0 ft. 12 IL Bentonite celieerhie
Non-Water Semi:.Writ: n. ft. i
®Monitonni ORccoven .----
Injection Well: n. ft.
LlAquifcr Recharge DC)roundwatcr Remcdiation 119.SANDMiRAN'I:L PACK'lif atydkablrl
i PROM to %IATI:RItI FMPt..srTMMv.\TMrtnon
DAquifer Storage and Rccotrn ❑Salinih Barrier 16 R. 33 ft. Gravel pack #2
DAquifer Test ❑Stommatcr Drainage
rt. rt.
❑Experimcntal Technology ❑Siihsidcncc('otaml
IS DRU.IP4G LOG WW1 additiostl•ihtYl.if Meehan)
❑Geotliennalt Closed Loop t ❑Tracer ROM TO , Otis RIFTiiJ\i,olr,hcedc..,riil'n..i.nor.,•r..s.ire.ele.I
OGeoihemaal(Heating+Cooling Retumi oOtitet(explain under 021 Remarks) ft. ft.
ft. ft.
4.Date W'rll(sI Completed: 6-26-24 wen IDigMf-32 '
rt. ft.
Sa.Well Location: It. ft.
Hamilton Beach ft. ft.
JUL3 ! 2G21
FwNiro,nunor N;i MC Pasha In .r,.rpl..rhlei
II. ft
261 Yadkin Rd., Southern Pines, NC, 28387 !'�`ir�� �i3
Plnswal Addlcss,Cite and Zip ' 21.RI M tRIeS '
Moore Bentonite seal 12'-16'
('non,) Morel ldcntdical ion No !PINt
Sh.Latitude and Inngiturk in dcgrccsiminutrs/secnnds or decimal degrees: 22.Certification:
(if well find.nir I:it.Intn is sidliickinl
N W I�'-Z----"--- 6/26/2024
Sitnatu..of�Well Contractor Dote
6.Is tare)the w ell(sY: 1oPermanent Jr tJTrmporan M.,i•nm slab tm,I hrrcM rr
4 g Jroreify Mal air arias)ow(urrr)constructed in anrordmirr
Hatt I SA NCAC 02C.0l00t or l SA NCAC(I2C.0200 Well C,metro,n,w Sonic and:ha:a
7.Is this a repair to an existing well: JYcs or KNo .,,r•,•,(Phi,record ha,barn pr.madd re.the,n)I.....ner.
If this as a reparr.fill,wt kneww well comings We mfarwc.o.n,and r epktit the na itre of At
repair under 02I rnrwrkcc sn see.n or em the back of this form. 2.1.Site diagram or additional wdl details:
Post nisi use the back of this page to ptos ide additional well site details or well
8.Number of wells constructed: 1 constmctioti details. You ina_s also Mitch additional pages if necessary.
For multip/c',.tierrMn or rout-arum r.apple well:ONLY■Oah the s.rnte.ri msrarnan tee,eon
sabm,0 one horn. Sh BMITTAI INSTUCTIONS
9.Total well depth below lard surfaces 33 (ft.) 24a. For .40 Wells: Submit this form tsnhm TO days of completion of well
for muiupir cc rli.:iu lea depth,,r der;•,„..,esowlph--N.? NO'aid 2 fr((ITt constriction to the fol►nning.
II.Static water level below top of casing: (ftl Disiskin of Water Resources,Information Pricesaing Unit.
IJwon',leer,is ithose.arag.axe 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter:6" (ia.1 tab.for'elation Well:ONLY: In addition to sending the form to the address in
24aabove. also submit a copy of this form within 10 days of completion of well
I2,Wcll rnnstnsetion method:Roto-sonic consiniction to the following.
,i c saner.reran.cahlc.diced puck tact
Division of Water Rrsuurecs,Underground Injection Control Progran►,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail scrs ice Center.Raleigh.NC 21%99-1636
211'.For VS AVE MIpith 8 Injrt'tion N'clls:
13a.1'idd(ltpnt) Meshed rf test: _
Also submit one cop, of this loon nithin N) dae s of completion of
IJb.Disinfection type: Amount: well construction to the count) health department of the county;where
constructed
Fonn GW-I Ninth Carolina Lbmonnrnl of En%imrmltYu aid Nat.ral Rcsorrocs-Dnmos of Want liesouca5 Re%wed.Aygust!1113