GW1--05346_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD
For n+r owl Use oNL.Y-
Tlos Porte can I,<iiscd for sink or ns.lnpk uclls
I.Well Contractor Information:
Tyler Brown moist i to I iw'91•RIP)ION
Weil Contractor Nam: h, ft.
ft. f1,
4625-A _
NC Well Contractor Certification Nun to j ill,OUTER CASING(tar rnuki.(arrd v.ells)OR LINER tit Nesbitt
FROM TO l to;NrTFit TIIICIO'rss MalTRtal
SAEDACCO h. ft. I is.
(oitpom Nam: li INNER('A.IN(.OR 11 BING jjeethertal dosed-kepi__,_.
/ROrt to n1SMETER tnl(-KSFSS MATTRIAI
w•
2.Weil Constftion Penult#: 0 (I. 8 rt. i 1 irk SCH-40 PVC
Lu all applicable urn pennies tie.County.State,Variance.Injedien eA-.1 I-- •
ft. h. lc
3.Well Use lchcek well use): l'.ti(RLEN
W'aterSup)dy Well: now to blame-me MOT SIPS THtCtt!il4(S MA trot 41.
in. .010 SCH-40 , PVC
LIAgrwultutul OMRnicipal'Pubhc 8 R. 10 ft. 1 i
UGeothetmal tHeatingCooling Supply) OResidential Water Supply(single) It. ft. so.
OlttdostriaUComnaen ial OResidemial Water Supply(shared)
MO* TO MAIERVU. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 II. 1 h. Portland Poured
Noy-Water Supply Well: —
h. fl.
❑Monitonnl; ❑Recovery ,
iajectios Well: II. fi.
O,Aquifer Recharge ❑Groundwater Rcnicd ration 19.SANDr(.ltt,S EL PACK(ra predde)
PROM ii. - MAT*RIMI. YM►I.MTAIP\T MI-TBOn
0Aquifer Storage and Recovers ❑Salinity Barrier 5 h. 10 ft. Sand #2
❑Aquifer Test ❑Siomwatcr Drainage — '
It, ft.
OEspcnmcnaal Tcchnoiogy ❑Subsidas:c Crnaml
20.DRILLING LOG iatiadh additouai sheers if stew an I
OGeothemialIClosedLoop, ❑Tracer mom to , t1r-rC'OPT ION r.ni.r,sardtte...wil,nui,n pr.gran..+.-.tit
OGeothemtal(Heating/Cooling Return) ®Other iesplaut under 0121 Remarks: h' ft.
ft. tt.
4.Date Welt(so Contpleled: 08/26/2024 Wdl IDI,GP-15
ft. It.
5a.Well I.nrati n: ft. ft. •
`'�mo d,..: ter/ fw • 1
Hanover Road PRLF It. R ;✓
F.•icilit.'Clw err Nana Facility IDa Of applicabkl S E P 0 0 2024
815 Hanover Rd., Graham, NC, 27253 fl. ft
Ply.s.c.03ddrrs�(it..and Tip 14RdNAlI1KS Ir("`y4:41."`3sloc.'oMt,• u4.4
AlumnaeBentonite seal from 1-5' D'hre/1CZ;
County Parcel ldenidtcaiioi No I PI♦1
5b.Latitude and Longitude in dcgtresiminwteslsecnnds or decimal degrees: 22.Certificatitr•
Orwell held ..a I:n•L,uc is std lh tint)
W
,J 5rL�"�---_` 8/26/2024
Si ,ofCcnificd Well Contractor .______- D.tic
6.Is taro the wrilisl: X1 Permanent or I t'Ir11N/r'ars By signing dal fr.mr.1 hereby certify that the Wel.YI war(were)constructed or accordance
with I SA NCAC 02C.0100 or 154 NCAC 02C.0200 Well Conant.**Saiaiard.,ard gist a
7.is this a repair to an existing well: Li'es or E No r,>ps-of dill rW card hit,firen prorated to)h,••u01 owner.
if chit is a repair.6111OH inaurl It r i,.noon;ru,nion mifornaaani,irLl a rpiaat OW NMI,C 'f air
repair under 0121 remark..sr,lino of,.it ri..hack of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells cosstrycted: 1 consimction details. You may also allach additional pages if necessary.
I on mulirltir Jr,,..tru)I,N n,vi.unit', a,q...a rlh ONLY situ flir rail(t'anlrrgrfAm toil can
sabutaorm firm. SUBMITTAL INSTUCTIONS
9.Total well depth below lard surfat= 10 (fl.l 24a. For All Wellig Submit this form wiihm ZO drys of completion of well
,,,„,., , ,,r1f.11.r„a4,•fvb,rf.lrRi•rr.all•.ratnp(e.,f 201anti2E1'10(Y1 construction to the following'
III.Static water lesel liehiw sip of easier 0 (ry,l Division of Water Resources,Information Processing I.nit.
If wailer hew!u above casing.u,• - 1617 Mail Service('cater,Raleigh,NC 27699-1617
11.Boteltale diameter:2.25" tit.) 24b.for Infection Wells ONLY: In addition to sending the form to the address in
24aabove. also submit a copy of this form within k)days of completion of well
t2.Well anoints-Don Ractllod:DPT construction to the following.
n e auger.scan.cable.dircit push ctc.1
pisirion of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Iit.it.Mail Men tee Critter.Raleigh.N( 211199-t6 i6
24c.For IA ACT Supltis A.Injection Wells:
I3.r.1 iced(elan Altflout of test:
Also submit otk copo of this fulfil withio :u daysof completion of
I nth,.Ituinfectii,n to per Amount: well constriction to the comp. health department at'the comet where
constnicicd
Fonn GW-t snnh(Troth::Licpanntcit of Em tmmrm anti Natural Resources-Divans of Wales Resotr(s Re.cud.Atgtrst 20