HomeMy WebLinkAboutGW1--04550_Well Construction - GW1_20240731 •
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used sot single or nadtipk%ells
1.Well Contractor Information:
la.WATER ZONES
Stefan Smith rMOM TO Dttit'Rtrllov
Well Contractor r Name R. ft,
R R
3576A
r Certification Number15.OUTER CASING der multi-eased Near)OR LINER(U lip 1kabk)
WHOM TOHIAMFTFM TTIK'K%TSS S MA1TMt\I
SAEDACCO 0 ft. i 5 ft. 2 in. SCH-40 PVC 1
t'0 ngcm+N.,mc 16.INNER CASING OR Ty BING l jratbrrnial elated-Wop) i
WHOM in DtANFTEH fnit'h"F>5 MA TTRUI.
--2.Well Construction Permit St: 1t. ft. fit — —
Lia all appiirabk well prniuh tee.CaaraV. Sher Variance.iiyercal en-.: -
R. R. w.
3.Well Use(check well uses 19 SCRIELIt
Water Supply Well: tntOM TO otANrrru st,TSW THH/i51Ot MAtmAi.
LIAgtxultural °Municipal Public 5 R. 15 ft. 2 is O10 SCH-40 PVC
°Geothermal(Heating.Cooling Supply) °Residential Water Supply(single) R It ra' I
0IndustriaUCommercial OResidemial Water Suppheslrnred) 1m'CROUT
t WROM TO MATERIAL [M[.\CEMEVr METHOD t.AMol vT�
❑Imgatlon i 0 R. 1 ft. Portland Pour
Non-Water Supply Well:
R. R.
ElMamtonne ❑Recover ,. —_• __
Injection Well: ft. ft.
°,Aquifer Recharge ❑Groundwater Rentedia Lion I9.SANDdGRAVIL PACK(if appneside)
WHOM TO _ M STBEUL EOM.ttEHrNT MtTnnn
°Aquifer Storage and Recovery ❑Salinity Barrier 3 ft. 15 ft. Sand #2
❑Aquifer Test ❑SIomtwatcr Drainage
ft. rt.
OExpcnmcntal Tozhnologs ❑Suhsidcmc r'olrml
26.DRILUNG LAG Mach atdlBliemi seedy it aces art l !
OGeothemwl(Closed Loupt ❑Tracet : WHOM TO tresennTms I&orr,hardw.v.,r.it4 w4 oa.r.cram..t..«1
DGDothemial(Heating'tooling Return 00ther texplain under 121 Remat►s) 0 ft 15 /t Silty sand
R. ft, Js • ._..
4.Date W'ell(s1 Completed: 7/9/24 - Well IDA1,84 f .-5 R. ft. •� `. s `+ t iL'
Si. •
Well Location: ' ft. ft. JIJL 3 ' 2G24
Col train Property II. ft.
PnettitOyrerN;lnt Facility NNlifapplicable) — ...-.;.,.C'�.�e.11
It. ft. VIA:..pr- .:
. i j
4541 US Hwy 17, Williamston, NC, 27892 R. 1— fi.� —pr
Physical Address.CM.and Zit ll,RCMARks
Martin 2 foot bentonite seal from 1 to 3 feet.
Comm I'.a.,i l.k Ili rro.1li,.n NO r PIN)
ill.Latitude and longitude in degrees/minutes/seconds or decimal degrem
(If well field.m,e ial'oug,x%udf ciem 1 22.Cerdficadoa:
35.791327 N 77.059208 W i7/10/2024
Signal ofCe,lied Well Connector teats
6.IS(are)the wellls): Xi ennanem or ❑Temptirar• gs signing Nair fen*,t hereby certify that the*was1 war twrrr)ewarmn7ed HT axrontmycr
with 1 SA NCAC OK.0100 or 154 NCAC 02C,0200 Weil Col atnrrcnon Standards and char a
7.La this a repair to an saluting well: JYes or ENO rt>jry Of Air recant ha,been pr..rded to the>.yfl owner.
If Oa u a repair,fill owl*orrwm well.,"..:nwr now iwfonn.rlitnn and explain the aware of Or
repair order 021 remarks m-tian or on the bat of ter faun. 23.Site diagram or additional well details:
You ntay use the back of this page to provide additional well site details or well
S.Number of wells arultrreicted: 1 consiniction details. You may also attach additional pages if necessary.
For a ltipk inferrh»I.a n 0t'..oer twpplo Welts ONLY wall thy limns c0narIetien.sew run
sabrairone f.raa. StIBMITTAL INSTUCTIONS
9.Total well depth below lard surface: 15 au 24a. For All Willa: Submit this farm withm ?tl days of completion of Well
For mahepk Kell>h.t u8.lrprh.rileOi•fou ie.raw.pfr-10700'.awl.'a'list'} constmction to the following-.
10.Stade water level below top of casing: 8 (ILI Division of Water Resources,Information Processing I
If Miler keel a oboes roan, am-"+ 1617 Mail Service Crater,Raleil h,NC 27699-1617
II.Borehole diameter:8.25" (110 24b.for Injection Welb ONLY: In addition to sending the Cam to the address in
24a obey e. also submit a copy of this form within :tO days of completion of well
12.Well construction method:HSA cotlatmc'tloll to the following.
tie.auger.rotary.cubic.ditch push etc.)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699.1636
13a,Yield(Rpm) Method Olpt 2k For W liter Nupplt ti Injection L�'.lh:
Also submit one cops of this form as Orlin :n days of completion of
13b.Disinfection type: Amount ----_____-- _--- well cotislnrctian to the comityhcahb department of the counts where
constntctcd
Form GW-I North Carolina Nutting-in of Ens imimrciu and Natural Resources-Division of Water Racemes Res wed Algtat H111