GW1--05410_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD r•,,by;law'.t .e fiNI•,
The form Can iv used fix single of nu.110 ttegs
1.Well Conte/Moe Information:
N.WATER ZONES
Tyler Brown roust To j nest RIP/ION
Well Contractor Name ft, ft,
•
rt, ft.
4625-A
NC Wdl Contractor Certification Number 1S.OUTER CASING(far amNicatrd serif OR LINER 11 apj1hcatk)
ON TO MANI-fro Tnutci -ss m%nutXI —
IR
SAEDACCO 0 ft. 115 ft. 2 in. SCH-40 I PVC
1
Conlp:an Nuns le.INNER CASING OR T 111ING(1ieaNerral closed.1o.pl--i-_---- ----
IROM TO r1AAQTER 'OM tatss st sit uiUl
2.Well('onsmictilnt Permit M: ft. R. a
Lau all applirab&well prnoitt i ir.C•ounty..Statr.Variole e,li&Bart rtr., - { — __.___.-.
R. ft. �-
3.Well Use(cheek well use): 17,fl('RtUN
Water Supply Well: • IlOM TO DIAMr1rR MOT-sin li NH evfs NSTKatU. ,
LIAgricultural LIMuniciptliPubhc 15 ft. 25 ft. 2 7a• .010 SCH-40 I PVC
OGeothemlal(Healing/Cooling Supph) LtResidenttal Water Suppl'!single h ft is
ObdustriaUComnlercial I IRcsidcntwl Water St ty ,ftot T
Supply 1Isds1 I MATERL.M.. EsrW.%IFmm.14£rAODaAMOUNT
❑Imgattan 0 ft. 11 ft. Portland Tremie
Non-Water Supply Well: ft, h.
RMonitonne ❑Rceoscn •._
Injection Well: O. IL
❑Aquifer Recharge ❑Groundwaier Remedial ion r'".s.s\nl.R.tVEL PACK(YtgtllleaMe)
F-kl PO 1,3 j st ATM U. TOPIAIFH1S N t rtnOO 1
OAquifer Storage and Recover' ❑Salinity Ramer 13 II 25 ft. sand #2 1
OAquifer 7cst ❑Stortmatcr Drainage - -
n, h,
❑1 xpenmcntal Technology ❑Sailsiderkc Control M.OR II I ING LOG Ialtach additional sheets if Neeessan I I
OGeothemtal tClosed Loop' DI-racer t.Itlssl TO ni)trawrioN it. r,a.srd.e.,r.ilwwL np.,.grro,.rc,rk I
O rn Geotheal IHeanug"Coolitie Return OOtlter le'plam m under P21 Reloads,' ft. ft.
i n. O. }
4.Date Well(sl Camplchd: 08/21/2024 well IDaMW-03 S h, ft. t r�. ;� `p" .,
5a.Well LucatiOn: ft ' h v n 2024
GOOD YEAR TIRE CENTER ft. ft.�-
Vac tlin 0wnet Naui. Faedin tD#cif applicablcl - -- lf.>r`-ry� ,�.
CV
ft. II. ti--...1
iti
1405 Jake Alexander Blvd W. , SALISBURY, NC, 28147 t. ft.'-
Pin skill Addtcss,Cin.and Zip I-21,RCMARK5
ROWAN Bentonite seal from 11-13'
Comm P.ncdkkrn,F :atooNo INN
Sb.Latitude and longitude in deremsemlinsteiuSeconds or decimal degrees:
22.Certification:
Orwell field.one 1:311,31v i.sidlicicnn)
1 �,��
N w _ 8/19/2024
Sismtu.ofCertified Well Contractor Dole
6.Is tare)the wellts): %Permanent ur OTempttran
Br**Mg All Mon,1 herein rerrtfs that the wrllt.l7 was Inn eknIsfNtled In accorri Tice
with 1 S4 NCAC 02C.0/00 or 1 SA NCAC 02C.02200 Well Omani,.non Saln.la.dl and rltas a
7.Ls this a repair to an existing well: .71tes or IO No raps of dui,reran!has Men provided to the sell owner.
If thld Ir g relMtr,fill min*MANS will COeOrtrr ROIL union heat anal r%pivot Ow oarare of the
rrp it wider I21 rewma,*s meteors or rat the bulk of tax form. 23.Site diagram or additional well details:
You may use the buck of this page to provide additional well site details or well
8.Number of wells cnmatree : 1 cofstniction details. You may also attach additional pages if net:essan.
For maltepk aejeethtn err o,um-.,,.art tuppls wells ONLY with air UMW cans/ruction s„u,an
submit,me p•ru. SUBMITTAL INSTUCTIONS
9.Total well depth below lard surfatc 25 (n.) 24a. For All Wells: Submit this form ssthan 11.1 days of completion of well
For mwhiplr stilt list all tAprht ifdiffrrent lr.ttnnple-202O0'unit:Ea'loot construction to the follnwing-
1e.Statk water lesel below top of casing: (RA Disisirn of Water Resources,Information Processing I.nit.
If Weller leer!u More!,issue,as'-. 1617 Mail Service('eater,Raleigh,NC 27699-1617
II.Borehole diameter:8.25" (111.) 24b.for!election Welt ONLY: In addition to sending the form to the address in
24aabose. also submit a cops of this form within in dos of completion of well
12.Well construction method: SSA cottstmcliun to the following.
li.e.alga.talon.cable.disco puck etc 1
Division of Water Resources.Undcrgr,und Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Set ice Center.Raleigh,N( 27(.99-11136
13a Yield Il pnu Vlctland oiliest:
24e.For Water Supph &Injection Welts:
Also submit one copy of this furs ssithou In days of completion of
I311-hi.infcctiun is ale: lnwumt- well constriction to the county health deportment of the counts where
Constntcted
Form GW-1 Nonh Carollia Depaamem of Em totunctu rid Natural Reeowecs-DKeioe of Water Resotrca Re;sod August 2011