GW1--04678_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For lncntol Use ONLY.
This form can he fined roc sinkk of nadlipte wcllc
I.Well Contractor Information:
II.WAVIER ZONES
Robert Miller roost 1 to DIESCRIPTION
Well C'olareclpl N.inie
ft, ft,
ft, n.
2675
NC Well Contactor Ccnifialion Nan bet IS.OUTER CASING der aseitkased Nelsl OR LINER IV ap Ikaak)
FROM TO MAMFTER TKK1OTNS NIk Fmk,
SAEDACCO 0 rt. 21 n. 2.25" ia. Steel
('on>,uut)Name IR.INNER CASING OR TUBING BING t jpstaertaal clssed-fttael
_FROM TO ? DI%MITER TMKXNESA 1 MATERIAL
2.Well('nnstrvcti n Permit 4: R. ft. j IL
hot 011 applii nf1L•wrl Lenoir.fie.Caauv.Sitar.Variance.*0104 em.! - - • -
n, n. ..
3.Well 1'se Icheck well ese): 17.SCRII.tN _.
WaterSupph Well: FROM To DI
FROM _ units-VI THICISNIOS MATIRIM.
UAgracultutal OMutakipal:Atblrc 21 It. 25 ft. 1.25" in. .010 Stainless Steel
OGeothemtal(Hearin ,Coolie Supply) OResidential Water St n, ft. is
K 6 =�. Supply(single)
OIndustriat'Comniercial OResidemial Water Stppl)(shtred) TR GRO(I.1
PROM TO _ MATERIAL EMPLACEMENT MEMO a.AMOUNT
❑iengatton ft. n.
Non-Water Suppl-Well:
ft. ft.
II Monitoring ❑Rccosrn• ,
Injection Well: rt. ft.
CI.Aquifer Recharge CI(imtindnatcr Rcnicdi:uion 19.SA?D!GRAYEL PACk(Il aelrealle)
room To soATRRIAI. RIPIACEMRVTMETHOD
OAquifer Storage and RP:m.0- OSalinit} Barrier n. n.
❑Aquifer Test ❑SMrmncncr Drainage
ft. ft.
❑Expenmcntal 1 ..hviologx. ❑Subsidetacc Comm!
20,DRILLING LOG(attach adiltlwY dumb(f aunnitan i
DGeothemtal Closed Loop ❑Tracer most To DESCRIPTION(yaw.bailee.,wawwk13 pr.VS.'w•.ttc.I 1
O Georheal(HeatReturn)Cooling Return) DOther(explain under al I Retnatka) n mt
R. n.
4.Date WADI Completed: 7/22/24 Well IDSB-1 - .._E... ". . •
n. n ..r r .I �. -:
S i.Well Location: h. rt.
US Car and Tool n. n. "r3 2074
i.:._,i n Owner Nam Facilm 11314(ifaipplicabkl A. - t
214 W. Hanover Rd., Graham, NC, 27253 R. IL
P111Steal 3ddRSS Crn.and Zip 11.UMARKS
Alamance Grab groundwater sample collected via SP-22
(tnu.n P.ireclhkmilk:Ai'uNo nPI
Sh.Latitude and Longitude in tkger aimirmtcs.sccnnds or decimal degrees: 22.certification: —..
ill well field.one 4mtans Is♦of Beleml
W )(44 �y/� 7/26/2024
SigN1UR of'.'':' _ ':.�;... NK+— Dote
6.Is tare)the Nellls): ;'Permanent ur 2CTempnran .0,,r•min'As
,� A form 1 hemh'verr((t that the went's)tatter Nen)comouctret,"occortl@n Y'
WA 1 iA NCAC 02C.0/00 or 154 NCAC 02C.0200 Well CrmsMw'rron Standards um/duty o
7.be this a repair to an existieR well: =JYcs or K No e41,1 of fieel rr.f ord l„rr!wen l.rnrvlrd rr.lhr sell owner.
If Otis IS a rryutrr..(ill owl know,,urn,MONM.Pf o,Intimononos,irul r.%plot',Ow moire of die
repair rosier 421 remarks sn9iun or on the hark of flax form. 23.Site diagram or additional well details:
You that use the back of this page to pros ide additional well site details or well
8.Number of wells coestrected• 1 construction details. YOU max also attach additional pages if timessar'.
for multiple injection or nmi-sitter s'welis ONLY with de warm eoastrio rl, r •..:n,urn
.twbnuruw.e form. SIIBMITTAI INSTUCTIONS
9.Total ndldepth below land wrfaec 25 ((f,) 21a. Fur All Wells: Submit this Itmu within :u doss of completion of well
For autarplr wail list all depth,tfdrjh'rent ro ett4PAr 31P=Or dnd 7.0 fool constntction to the follnnita};
IS.Static water level below hip of casino: (ft.) Division of Water Resources,information Processing 1 nit.
ff wn.'rr lr,r,' ,t o,a.,sear.use 4 1617 Mail Service(cater,Raleigh,NC 27699-1617
11.Berekele diameter:2.25" ) 21b.for Injection Wells ONLY: In addition to sending the form to the address in
24aabose. also submit a cops of this form within :lei doss of completion of well
12.Well eneasraceton method:DPT construction to the following.
0 c.anger.Foram.cable.dims push etc I
Division of Water Resources.Undergnoned Injection Control Program,
FOR W ITER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699.I636
Ida.Yield litpntl Method of test:
Ile.For Water Sapph R Injection Welk:
Also submit one cops tit tins fume, nnthm to dal s of completion of
1311.Disinfection type. Amount: well consmlction to the ,„inns health department of
of the county whew
cos ntntcied
Forte GW-1 Nola Cambria Deponnaent of Em troimaiu and Natural Resources-DisIrmo.,l A di.i ge otre Reseed Atgt6t 2013