GW1--04627_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD 'For Internal UseONI_s
The form can be well rot sunk or nndtipk ocils
I.Well Contractor Information:
j II.W'AMER ZONILS
Robert Miller r11OM ; tO , Mrst'RtPtnrx
Well Contractor Name
' n.
n. ft.
2675
NC Well Contractor Ccnification Number 1S,OUTER('iSlNG(for uI I-eared cams)OR HMV IN opallirabkl
PROM TO MAMfTFIA • TRIt NNTSS \I ViTRMi
SAEDACCO 0 it. 1 21 n. 2.25" ie. Steel
I4.IN NIX CASING OR TUBING T cIm
( uys:un Name +.�.._-..�. (tomhermal-._..._.�__.d'fira1l.1. -_-----_..
FROM TO DIAMETER THICKNESS _ MATE RINI_
2.Well Construction Permit Y: n. ft. la i is all applicable well permits ler.County State,Kiwis.-r.lrfebbt etc.)
n. n. n. I
3.Well gale(check well ascii t7.SCRLLN � —_
Water Supply Well: rmom TO DIAMETER slat MST THKTtst1S. MSTxits!.
.010 Stainless Steel
UAgrwulturai OMunisipal+Atbhc 21 ft. 25 ft. 1.25" OIL
OGeotheal(Heating
Cooling Supply) DResidentlal Water Supply(single) n' n l is
nn
O htdustriat/Commetcial OResidentwl Water Supply(slsired) iS'Cr��
IrROM TO MArt?mlAi. EMt'[ArEMEVr METROD a AMOUNT
❑lm gat mn n. n.
Nun-Water Supilh Well: - ----r
n. n.
IOMontonnp ❑Rccmrry _,
Injection Well: n. n. 1
El Aquifer Recharge ❑Gmundnaler Rcniediation IT.SAND/di AVRLPACK Of applicable!
PROM T() Mitt MU tNW.“INIF\T Mrtntrn
❑Aquifer Storage and Recovery ❑S.alinin Hamer n. ft.
❑Aquifer Test ❑Siomoater i)rainage
n. ft.
❑Expenmcntal Technology ❑Sahsidericc Comm!
*DRILLING LOG t attach adiidoaal Ards if,aeinan t
DGcothemtal(Closed Loopt ❑Tracer PROM In DRSC RIPftON Is*tsr.hednre....il'o..1 is pr.xr.n.m'.ra I
❑Geothentaal(Heaung&Cooling Retuntl DOther(explain under s!I Remalta) n- n.
4.Date Well(sl Completed: 7/22/24 Well iD,B-2 l: I
s.- .... 1...1i.i
ia.Well Location: n. n. A U G 9 5 /024
i7S Car and Tool n. n,
FIKIlm Ounce Mete Facility iDatilappls:abki I.
- I/by,rAaw!C.l Py'S' D'4 U
R.
214 W. Hanover Rd., Graham, NC, 27253 ft. rt
PM sicnl Address.Cif".and Zip 21.REMARKS -- -- - _ - - -
Alamance Grab groundwater sample collected via SP-22
...I.', .-..- Farrel lden dw.alion N. I PIN I
Sh.Latitude and lasngitude in tk'grtcsiminulrs..eennds or decimal degrees: 2/.(crTiftcanon:
O(well IRN.one lationg n sidfic w nl i
N W x rt 7/26/2024
Signature of c'.,`.`::C, - ...� 7,4..e.�._ Crate
I..Is tare,the ssell(sl: Permanent or HlTemporat' '�y.
ity.signing axis form.1 hereby terrify that the wswiss)mu farm)[YMrrILt7nd N scrams/Kr
with 1 S.A NCAC(12C.0100 or ISA NCAC 02C•0200 WrU Conor,tn'ar Satrrdenda and that a
7.Is this a repair to an existing urn: Dlies or ION, .corn of dill-rernnf has been provided to the urn owner.
if aNb u o rrpeir.fill,.rut to,.na..ell,,Niettin nuts tnfornarranr oast a spt.rm Ow,tir,.rr of rhr
repair owlet*21 remark.,..-,-,i..n of..n the bark of thls form. 23.Site diagram or additional well details:
You may use tie betek of this page to proside additional well site details or well
Ii.Number idsselhamstructed: 1 contiirudtiondetails. You item also anaeh addilional pages if IeeessaI%.
f,.r•..i, :.I.N Iv/An-nearer ogtpts welts ONLY WWI else same ramrrarr/.w sun,unN
sr l S.[BMLTTAI,INSTUCTiONS
9.Total well depth brim land surface: 25 (fl.1 24a. For AU Willa: Submit this lunn within Mi days of completion of welt
Far maim*wells hsr nil deprhr rfdtgrrrnr reran*.3 200'and 20100a construction to tie follonini;
I0.Static water level below tap of easing: (rt.I Division of Water Resources,Information Processing l nit.
if nertrr lot,'es alt.,r,.tslnz.u•• - 1617 Mail Service('cater,Raleigh,NC 27699-1617
I1.Bereh,k diameter:2.25" (IL) 24b.For lnkrtlon Wells ONLY: In addition to sending the form to the address in
24a abuse. also submit a copy of this form ssithin I0 days of completion of sell
12.Well coeatrwetion method:DPT construction to the folios%tog.
tic.auger ratan.cable.direct pusls cue.)
Dishful'of Water Rcsnurtes,I ndergr,tund Iuiection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Nrrs ice I.enter.Raleigh.NC 27699-1636
13a.Yield*poi Method off: tic.For Water Nuppls it'..Injection Wells:
Also submit one cops of this lints n ithm sou des s of completion of
i3b.Disinfection hype: Air well constnlctlon to the county health dcpanns nl of the coital\se heir
constructed
Fonn GW-t North Catalina lkporentetu of Ens ttotm►MI aid Natural Resources-Dnneon of Water Reiarcm Res used August lot 4