GW1--04576_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For llacrml Arse ONLY:
r,..,corm can be ii d for single rat mmdupt;,,..?Is
I.%%ell Contractor Information:
' 14.WAITER ZONES
Tyler Brown VNOM 1 TO D)'tir RIFT I .
Wcn x Corarror Name ft, ft
n, n.
4625A
NC Well CaiewctlwCenification Number moist
OUTER CA-SING(liar awMi-sail cells OR LINER II t,kratkf
roost ; m I ntaxlrtiN TIOUNNT[, a11 attRf al
SAEDACCO 0 fl. 36 It. 12 in. SCE-40 PVC
('onyrluq N.mnw MANNER 'ASING OR 77.'11ING jstherneal cbsed4uepf
IIIOM i0 DIA.NETER r111(6NtN• NI 1111(I11
2.Well('nnstru tioo Permit N: ft. fl. Yt.
Ina all tool.all.w ell Fenno i i.r.('atom Slay.Variance.Inlet ell., -- f
fl, fl. it.
3.Weil1'se(check well awl: 17.!It'REEW —
Water Supply Well: PROM • to • Dra,trtrR Met NM THI(1111VIN Mat)alar.
❑Agricultural OMunicipal/Public 36 ft. 51 ft. 2 is 010 SCE-40 PVC
❑Geothenrol(Neating,Cooline Supply) Sun*Water Sup (single) ft. ft. is
Olndusttial+Commc,ial OResidential Water Supply(shared/ la OM IRON
IR TO MATERIAL j EyfrLy(rNf\T METHOD A.(NOl xTH
❑Img.ilion 0 ft. 30 ft. Bentonite c!Reerbie
Non-Water Suppls Well: ---
R. ft.
f. MontionnF ❑Recoser -- -
lajecflon Well: n. ft.
❑Aquifer Recharge ❑Groundwater Rentediation t9.SAND1(.RA EL PACK Of Iipplkahki
rttON 10 al ail:Rtal. )SIPI..0)'MIA1 Nrtn(tn —4
❑Aquifer Stork and Recovery ❑Salinity Barrier , 34 H. 57 ft. Gravel pack #2
❑Aquifer Test ❑Stortmyater Drainage
ft. ft.
❑Egtcnmrnurl IcchnologA ❑tirthsirkncc('onml 20,DRILLING LOG rttltath addlllsaalshrsrb if ma:asarn)
❑Geotbental(Closed Loup) ❑Tracer i ono i Tn sots(IIIYOOn maw.rndoe s,1.11; 1,nor.min sow.in I
❑Geothemal(ieatingiCooling Retumi ❑Other(explain under al I Retnaika) h. rt.
4.Date Well(sl Completed: 6-25-24 Wr4l IDAM-27 F .. 'i`i
Sm.Well Location: ft.' ft. JUL 3 1 ?024
Hamilton Beach ft. It,
FacdityllwtrlerName Facility IDN(ifappiicabkl �fr'�$L f►m•le., w.r.-,Rr�.(i'•.e#Urals
261 Yadkin Rd., Southern Pines, NC, 28387 R. ft. CY :e SCv
Plnsical 4ddicss.Ciro.and Zip 21.REMARKS
Moore Bentonite seal 30'-34'
('omits PJrcd Lknldtc,Iiun Nu I NI.I 1
Sh.Latitude and Longitude in d drer•s'minutes.'wccnnds or decimal degrees: 22.Certification:
(if well firki one taf,lons is suflkrcral
K W ,� 8-z--_` 6/25/2024
Sigma..of�Well Contractor 1.1,uc
6.IS rare)the NtIIIs): X PCtmincnt or Temporary 81.xgn ne that lino.I hrrrh.cern(r Thom the n'r1N0J im,(srRJ cv.moin a-rd at art- -dim,e-
w oh I 5,4 NCAC O:C.011a"r or f Sty NC-IC i7?('.0200 Well Conatemetiwr Swrakvdm and that a
7.Is this a repair to an e>tistisg well: =7Yes or IG No ..ryr,ref that reran/hen hr.,,prnruf S to the well owner.
if 1hi3 of a lrplfr,fill van*nt as nen,amino non tnforrnano r an/r rpiom Ow atrttre of rho
repair under 121 rrwvarki m-nan or an the bolt of this form. 23.Site diagram or additional well details:
Yuji was use the back of ibis page to provide additional well site details or well
8.Number of wells constructed: 1 CcalstmQiorl details. You may also attach additional pages if necessan.
Fur malnple infe4mil or aril-Rater agiplr wefts ONLY yeah der cairn enrtairweikea.sow mum
Mahan,..ir,•,.17!, SUBMITTAL INSTIICTIONS
9.Total will depth helrnr land surface: 57 (ft.1 24a. For All Wills: Submit this form within 1.t1 days of completion of well
For mulrplr arils hot au depth,if lrprrrto reaannpfe•(Q'O Y and:fr/JYYI constniction to the following
111.Static water Irsel hehtw sap of rasmt.: (ILL 1)is hiitn of Water Resources,Information Processing l nit.
If wall.,hint n•rl,...• 1a 17 Mail Service(Cater,Raleigh.N('27699-1617
II.Borehole diameter:6" l i n., 21h.for Injection Well..ONLY: In addition to sending the form to the address in
24aabuse. also submit a cops of this form within 10 dass of completion of well
II.Well cooatructinn method:Roto-sonic coltslnichun to the following.
li C.arrwer.rrwan.cahlc.direct push.awl
Dhision of Water Resources.Underground Injection Control Progtram,
FOR W'1TFR SI-PPLY WELLS ONLY: 1636 Mall Service Center.Raleigh.NC 27699-1636
2le.For IA ate'.Smalls A.Injection Wells
I3a.Yitid(Loran) Medial of test:.-.
Also submit our rope of this form withal iII das s of completion of
IJh_Disinfection q re: Aummmt: well co smiction to the county health detainment of the courts where
constructed
Form C,W-1 Noith Carolina Dcpmtnrm of Ent noiurcru aid Natural Resources-Do MOB of Water Resources RC%i cd August Ili]1