GW1--04577_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For lncrnnn Use ONfl
The form can be'iced for sinnk or rmsltipk nclls
1.Well Contractor Information:
14.WATER ZONES
Tyler Brown rani 1 TO , DYst'RIPI ION
Wc11 f'nnirhax Nana ft, ft,
4625A f6 ft,
NC Well Coisntcior(-cnifrcatron Number15.OUTER CASING(tar msNl-cased wens)OR LINER iW as liable)
MOM TO eisstrira TRICENrss MSTint+I
SAEDACCO 0 ft. 33 ft. 2 Ia. SCH-40 PVC
Conyrut,Nana IL INNER CASING OR TIRING ipeibernial ekt+eda•rnp)
riOM 1 TO DI.MFTrR 1 I lilt K\i.s. SIUTRISI '
2.Weil Constriction Permit 9: ft. I ft. is
ft. h.
Ira all awl,.able urn permit]fI.r.County Slate,Variance.fi)0al air.+ L`--It
3.Well Use(cheek well not: I'.'(RCEN
WaterSup(d)Well: TIt1M , to ORRM/TEM SIAT61LR 1111(10MIS MATRItia,.
OAgrwultutal DManicipal/Pttbhc 33 ft. 48 16 010 SCH-40 PVC 2 ia,
°Geothermal IHeating+Cooling Supply) °Residential Water Supply(single) ft' ft is
OIndustrial+Coninnercial OResidentwl Water Supply(shoed) 18
IRON TO MATERIAL tMPLACfMH.sIT MfTAOD&AMOUNT
❑Impation 0 ft. 27 ft. Bentonite ceileerhie
Non-Water Simply Well:
ICMotutonn); ❑Recovet)'
laJectinn Well: n. ft.
°Aquifer Recharge °Groundwater Rcntcdiation 19.SAND/GRAVEL PACE( PMcaN ape)—
VROM TO M ATRIUM. FSIPI.s(-VNV',INrtnon
❑Aquifer Storage and Rcco''et)" ❑Salinity Barrier 31 ft. 48 ft. Gravel pack *2
❑Aquifer Test ❑Stommatcr Drainage
ft. ft,
°Ewe- mental Technobgs ❑Subsiden:e(biaml 20,DRILLING LOG(al(aclt additional sltce(t if accession l
OGeothennal(Closed Loop i ❑Tracer PION to ' nMACK!?IION i coin,.hnr%Intsn, l ni k n g.os prsia va.ek.i
OGrotltetmal(Heating/Cooling Returni ❑Other texplain under 121 Retnarks)• a ft.
ft, ft. 1. t/ i
4•Date Well(s)Completed: 6-25-24 Well IDOMN-26 l; L.•- -
1.�itL.
5a.Well Location: ft. ft. — �IJL 3 ?G24
Hamilton Beach ft. m. l
Psciliry Owner Name Expiry ID"(if applicable) — KAW'' r '�
u. e. (rllb:r ([l�/ti'
261 Yadkin Rd., Southern Pines, NC, 28387 N. rt�
Plnsical Address.City.and Zip `21.mimics
MooreBentonite seal 27'-31'
Counts I',i.c]I.knl.ti�aln i N., 'PIN)
Sh.Latitude and longitude in tkgrcrs.minutcssecnnds or decimal delvers: 22.Certificating:
or well field,on.: at Into is stdll.►nil
N W I.3-z---� 6/25/2024
Sipmtuya,""
Well Conlaclor Dote
6.is tare)the wettish XPennanent or :_]Temporary
ll signing dui form.I hrrrbs rrrrrfq that the*AO!ow(*err'ounion-ted in accordance
with I SA NCAC 02C.0100 or I SA NCAC(12C.0200 Well Cansnwrtian Standards and that a
7.Is this a repair to an existing well: _]Pest or ®No cnpr of this r,•na.f has been provided to the urn owner
If this is a'spate,fill.u(boom IS nil.,nuNic I,e wforroarion.isl r%plait rla•moire of thr
repair ander In minim..,Yrclian or on(he bait,..f rhir form. 23.Site diagram or additional well details:
you mat use the bail,of this page to pros tde additional well site details or well
8.Number of wells eosmtrrcted: 1 construction details. You etas also attach additional pages if uaessan.
fur multiple infection of non-uwrrr sipnh-well:ONLY u'idi rhr same canitrlwllnn 1..0 ion
saMnir.aw form. SUBMITTAL INSTUCTIONS
9.Total hell depth below lard surfatc 48 (ft,) 24a. For All Wills: Submit this form within iu dais of completion of nell
For nwhipk wens list all depths ifdeffrrrnt fciowpk•t@200'and 20 l00'1 constniction to the following
Itt.Static water ks-el below top trf casino (ft.i Division of Water Resources,Information Processing 1 nit.
lit.?,'70..- n uhort•,asn,y . . 1617 Mail Service('cater,Raleigh.NC 17699-1617
I I.Borehole diameter:6" (IL) 246.For Injection Welb ONLY: In addition to sending the form to the address in
24a abos e. also submit a copy of this fonn within 30 days of completion of well
12.Well emistrwction method: Roto-sonic coletrodiun to the following.
tic anger.rotan.cable.direct push etc t
Dhlsba et Water Resources.'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Senior Center.Raleigh.NC 27699.1636
IJa 's idd Ieiuit Ott*: 21c.For ss near Sulryds &Injection Writs:
Also submit one cops of this form nithnt tin dassof completion of
IJb_Disinfection type: Amount: well consimet►on to the counts health department of the counts where
comanicted
Font GW-t Nonls Carohiu INWIIIIICIII of Ent tin uieni and Natural Resources-Onnion of Water Resources Res ued August Roll