GW1--05400_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (\\ For!MenialIlseONLY:
This form can Ix;used for sinjk or runllipk Hells
1.Well Contractor Information: \l •'/�J
RichU.WAlU U
Lemire
MROM to DP$('RII't1ON
Well Contractor Name n. ft.
2593A n, I n,
NC W'ch C am as 1 n ;ii l ,uon Ntttubcr I 15,outwit CASING(far mu and wend)OR LINER(if Stable)
VRON TO DI{METFN TRICK\rss M{TF'Oki
SAEDACCO ft. fl. in.
(•oupans N.ino I I&INNU CASING OR HIVING(Zear► -ti►ernial etnendop)
R._�_,..__.. ....,
-FROM TO DIAMETER THICKNESS {L{iEpI{t
2.Well Construction Permit#: 0 ft. 15 ft. 2 w. SCH-40 PVC —'
List all applicable well prated,fie.Counts.S&ae,Varian,rtlea[Orri eh.. ,
n. n. Ni.
3.Well l'se(cheek well arm: 17.SCREEN
Water Supply Well: anon 1 to D/AMITER sIAtMltlr th1(XNIONs I M{TrRtst.
❑Ago►Agricultural UMunteipal;Public 15 ft. 25 ft. 2 ia. .010 SCH-40 PVC
❑Geothermal(Heating/CoolingStipp))i I(Residential Water St rt. f6 ia.
•-tpp Supply(single)
❑Indusirial'Cont ocrcial I_iRcsidential Water Supply(shoed) IIIL Gil,O0T To MATERIAL EMPLACEMENT METROD a AMOUNT
❑bTt gat inu 0 ft. 11 ft. PORTLAND TREMIE
Non-Water Supiuly Well: ,
n. ft.
ItMonitonne ❑Rccoscry' 1
injection Well: ft. ft.
❑Aquifer Recharge ❑Gtoundwaler Rentediation le.SANDIGRAV!L PACK_Pf s lRtalke)
1,111114 TO MATERIAI. EMPLACEMENT METHOD
I./Aquifer Storage and Recover). ❑Salinity.Barrier 13 n. 25 ft. SAND #2
CAquifer Test ❑Stortmatcr Drainage h, ft.
❑Espcnmcrttal Tlxhmbgy. ❑Subsidence Control 24,DRILUNG LOG lattac►additional sheets if accessary)
OGeothemial(Closed Loupt ❑Tracer 'ROM TO DESCRIPTION µshr.heMaew,wda'nai ti pr.gni%.e'.tit.I
❑GeothemtalIHeatutg'CooliligRetunii ❑0111cr(explain under lr2lRematts) 0 ft- 11 ft. ORANGE SANDY SILT
11 ft. 25 ft. TAN SAND
4.Date Well(OO Completed: 8-23-2024 Will IDoMN-1
—
R. rt.
5*.Well Location: rt. iL ' !
S 1!Residential Property A, a. 1 �'a t» ��L.L;
Focilits.0ater`..r,.. Fool 1, IOr fitapplicable) R," Ill. t f) H 9 2024
5417 Watson Seed Farm Rd. , WHITAKERS, NC, 27891 ft. R
PI►sical Address Cln.gild ZIP — l rJ'-;r- t C,l ra"4-,t...y, 1 u�21.RCMARK.i NASH BENTONITE FROM 11' TO 13'. ()r�tr.l,J Ka
t'amsl) Panel Identification No IPIN1
I
51).Latitude and I Amgi ode in 11epeea/minutes/scconds or decimal degrees: 22.('eriificatloa:
11 aJ:a,ld me IA l.v__r.•adlia'n11
N W '� t/l��_,Qifv.v.-cam 8/25/2024
Signmue of Celt' Well Contractor Dale
Ir.Is tare)the%cuts): EPermanent or ❑Temporary
fit Aigning deb lam,i hereto rernfs•Mai the wseLlrt war Owe)cwatrire-ted in accordance
aim 1 S4 NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Conerrwrt(oat Standards ark!thou
7.Is this a repair to an existieg well: ]Yea or EN* reaps of Air record has been pmvreled to the well owner
if this et a rep air,Oil erar Moue'w•dl a,'/,lops 1uMr infarn,nsai 11141 a rplam the rkaitre of rite
repair under 021 remarks maum or on the bark of tidy form. 23.Site diagram or additlooal well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For malrq)r,virus thoi,n e,,H1•n'nte'r tarp).acee!!t ONLY wash rite ion.coesnaedea.sow evW
s ibsnsr.nie d.nn. SUBMITTAL LNSTUCTIONS
9.Total well depth below laud surface: 25 (t1,) 24a. For .AR Wclll: Subnni this fume withm io days of conipleton of.sell
For maltrplr welt list ell depth,ifdeftere•nt terompfe-30200'ankl..sm!!Mt S construction to the following
to.Static water level below top of casing 18 try-) Division of Water Resources,Information Processing I.nit.
if realer kiry1 n above rasing.ass"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter:8.25" (IL) 2-lb.For Iniertioa Well ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this form within =O days of completion of well
12.Well rouatruction method:AUGERS eommiition to the following.
si e aneer roan.cable.dime push etc.l
Division of Winer Resources,Underground Injection Control Program.
FOR WATER SITPLI•WELLS ONLY: I 611.titan Service Center.Raleigh.NC 27699-1636
13a Yield(gpml Method of Leff: 2k.For W atcr Supply &Injection Wells:
Also submit one cops of this form within 30 days of completion of
lilt.Uisinlitition h Amount: well consintcuntt to the county health department of the county where
:
constructed
Fenn GW-t Nanh Cuckoo t) iannrru of Ern iiutuu,ml null Natural Resumes-DnMoo of Wader Reams Rcs eyed August 201