GW1--04883_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD lam/ FwInternal Use ONLY:
Pi fornican be iscd rot single or io It pk i.rllti ` )
1,Well Contractor information:
14,WATER ZONES
Stefan Smith PROM r(s DVS(RIPtwr'
Well Contractor Name ft, ft.
3576A - ft. ft.
NC Well ComnxrorCcnification Number 15.OUTER CASING(Fir melts-card web()OR LINER figas *able)
!ROM TO MAMFTFR nut-t .Ews MATraist
asanaCCO 0 ft. 5 n. 2 tn. SCR-40 PVC
Compton Name /6,INNI&CASING OR TUBING ljarth ergial dasad'4Mai 1
ROM TO DIA s1FTF'.it TIIKl(NEu MATERIALJ
2,Wen Construction Permit N: R. ft, in. 1
1st all applicable wrllprn.ols(i.r.County.Sao,.Variance.&Ocean rt.r.) i r
h, n. in.
3.Well I"se(cheek well rut): 17.SC'RtIN --
WaterSupidy'Well: FROM TO DIAMETER Notsrrr i THICKHlrs MATRIt1Al.
Agriculnual pMuoicipalrPubhc 5 R. 15 ft. 2 is .010 'SCH-40 PVC
I IGeothemtal IHealing.Cooling Supply) DResidential Water Supply(singiii IL ft to
I I IndustrisLCornnlercial CIResidentwl Water Supply(shirr:) is (MOLE
i.i.iiiio i,i MATERIAL EMPLACEMM METHOD i AMOUNT
❑lmgatiin 0 n. 3 n. Portland Pour
Non-Water Su1gAy Well; n n.
N Mom tonng ❑Rccovcty e ---4
injection Weil: rt. ft.
❑,Aquifer Recharge ❑Groundwater Remedia(ion I �.('n(.It ss LL PACK(E.Vrlkaall} ,
k(t.i sit MATERIAL E`IPt.ALEMr5T METHOD
IAgnifcr Storage and Rccosety ❑Salinity Barrier 4 ii. 15 h. sand 2
❑Aquifer Test ❑Stormwater Drainage ril ft.
❑l ylcnnicMal Technology ❑Ssrhsidcricc Control ,, I)R11.UNG LOG Iartaci aidMbaal ihrrts if,lcccssan i
❑Geotliennal(Closed Loopi Di-racer Elitist TO , DESCRIPTION ioil..-.%Aida.-...'..Ails»!Mbar.pen..rr.tit i
❑Geothermal(Healluk+Cooling Return) ❑Oilier(explain under a`I Remarks) 0 fr. 2 rt. silty sand
2 it. 6 ft. sandy clay
4.Date Well(s)Completed: 7/11/2024 Well IDaMFf-1 6 ft, 15 h. clayey sand , .. - )
'I I...ii..'
5a.Well Location: ft h. ' AUGPete Dawson f, ft, A 2 b 2014
Faciligy,'OaaetName Friedley ION inapplicable) ft,
lr. �:z-;.:_: ' u7^sit 1
927 S. George St., Goldsboro, NC, 27530 It rt. s,, s
Physical AAiass,Chi.and Zip -i21.RCM ARIc1
Wayne 1 foot bentonite seal from 3-4 feet.
Coma) Parcel Identification No tPiNi 1
Sb.Latitude and Longitude in degrces/minmtesisecnnds nr decimal degrees: 22.('erTifWatira-
(Ifwell Geld,()It I:a long if udla:ictal
35.371616 N 78.006044 W' e!' / it6CV1 7/26/2024
Signal. of Cc,feed Well Contractor Dine
6.Is(are)the weIl(s): XIPennanert ur ❑Temporary
by signing Our fans.I hrrebr ferttfr rhea the wrll(s/eau(Emil crouroo red or an-orlmt.r.
RvM 154 NCAC ON'.0100 or 1 SA NCAC f12C.0200 Well Catro(rwt Non Sraudarth and that a
7.is Rik a repair to an existing well: _i lcs or ENO fops of Mir word has brim provided ea tAr i.rf rn.•nrr.
IflAis at a rrpalr,mow toms r.1.11,,m,Airt teem mformathut Aral r pins,tau•MUM!'of At'
repair under 121 remarks.'.u<m,r.yt the bad o.fthis form 23.Site diagram or additional well derails:
You may use the back of this page io pros ice additional well site details or well
8.Number of well constructed: 1 constnrction details. You may also attach additional pages if necessary.
for mihtipie infer nrm.a rnv,-surf,,topple 14Oh ONLY.rids th.•same consume:Ma .rw rim
.aA.nir one forth. SUBMITTAL[NSTUCTIONS
9.Total well depth beltrw lard surfaces 15 in,) 24a. Fur All Wells: Submit this Rim within 3ti days of completion of well
for mMltiplr 1.1'lli lot all d1'pthr rfdrf i real)erarapk-?@`2(M7'and'ar larn construction to the following
iu.Static water lesel Intim tip of casing: 7 (11.) Division of Water Resources,Information Processing l nit.
if arse.7r.rl r,ohm,,,,,,: .,, • 1617 Mail Service('enter,Raleigh,N(-27699-1617
I I.Borehole diameter:8.25" (roil 24b.for Injection Welk ONI,'t: In addition to sending the form to the address in
24aabose. also submit a copy of this form within 30 days of completion of well
12,Well construction method:BSA cm>Blrlu tiun to the follow ing-
ti O.auger.retan.cable.ditat push.etc.1
Di%isiin of Water Resources.Urdergrtrond injectiis Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 h1Ail Service Center.Raleigh,NC 27699-1636
13a.Yield tarn) Method sliest: tic.For\\suer Supld% .1:.Injection Wells:
Also submit one cops of this form a ithnt ;(( das s of completions of
I3b.Disinfection ty pc: Amount well construction to the county health department of the county where
constructed
ForaGW-t North Catoluia OsTanment of Ern uonnrni and Natural Resources-Di%nun of Water Resdlrcss Re;iscd August 2011