GW1--05411_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For lrocneiUscONI,ti'
The fortn can M sect rm single or rmrIl pk%wits
1.Weil Contractor Information: .-- • .,
1 14.WATIR ZONIiS
Tyler Brown r00% to er.(•RrmON
Well Contractor Hank ft. ft.
—4 r
4625-A • ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for maYitasrd wcNsI OR LINER Of or Ncabk)
roust i TO ntsmrTFR TNR'ANTVS y14T11041
SAEDACCO 0 IL15 ft. 2 ie. SCR-40 PVC
Ib.INNER C ASING OR ll'IING dsscd-too
('angsaq Nang t Ijeot�er>d P)
F WONI II/ M.SIFTER TNI('A\r\S MA TT.-NIkl
2.Weil Construction Permit if: ft. ft. IL -I
Liu all.appli.mile welt permits f i..r.Canner.State Variarr.JItK9d4 Air.) --
n. n. 1 ie.
3.Well Use(check well uses: 17.SCREEN 1 ___
Water W'aterSupplt Well.. rolls TO ; DIas1►TT:a slat sirs TNtc'Arlccs SlATPRIAI.
15
1_1Agnsultutal DMunicipalfPidllic R. 25 ft. 2 ix. _.010 SCH-40 PVC
mtallHeatinRooliR' ft. ra
[iGeothe ng Supply)1pph) DResidrrxral WaterSttpptt (single)
1 iindustrialiCommcrcial DRasidcntial Water Sttpph Isklfed► 11
43110177 7110M TO ' MATERIAL EMPLACEMENT ME11100&AMOUNT
❑lmgation 0 R. 11 ft. Portland Tremie
Non-Water Supply Well:
R ft.
RMortitonng ❑Rcoocen _-a
Injection Well: ft. fl. 1
_
❑A(luifer Recharge ❑Get u dwatcr Remediation 1111.FAND(.iLAVLL PA(A!if:ylltlic.able t__ {{
PROM 10 H.IF HI.I P.MPIAtVNIENT METHOD
DAquifer Storage and Recmcn ❑Salinity Barrier 13 ft. 25 tl, sand #2
❑Aquifer Test ❑Siomm net Drainage ft. ft,
❑ENpctal Technology ❑Stdlsidencc Control 1
fimen
24 DRILLING LOG ianach sdtlilioaal*et*if occesun t
DGcodremial(Closed Loop( ❑Tracer roost ' TO O RaPtomNttsl.r.harder..,w.itww4„rr.vide*FL olio
❑Geothemtal(Heating+C'uoling Retunti ❑tither(explain under s.I Rem.nt.,I tt. ft.
ft. ft.
4.Date Well(al fnmpleled: 08/21/2024 Well IDaM14-02-8 o- i r-'- '1 , 1 D.
Sa.Well Location: ft. ft. SEP
GOOD YEAR TIRE CENTER ft. ft. t r 9 ?09)
Pacilii)OanetName Facility tDe(if applicabk) --.____..-R.. ft. 'r.t'v:fS4i F,: ?•� Af..:L-'Ft 1!
24,
1405 Jake Alexander Blvd W. , SALISBURY, NC, 28147 g. ft." ekir1,t. ;�,
Mesta!Address.Cin.and Zip 2 i.RL'st AR c
ROWAN Bentonite seal from 11-1:3'
r;ome Parcc]Idcntdic:dioai No ;PIN I
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.('ertffkadln:
of ed t field.tow la'loeg is sufficient)
N W ,� 8/19/2024
Sigolm..of� 53�--�Well Contractor Date
O.Is tare)the Ntllls}: mPrlmanent or ❑Tteulperat} to 3i5ning ihu Form.I herrbs certify rhor the well&,5 wax Iwrrrl cerusruered an accordance
with I TA N'CAC 02C,0/,19 or I 54 NCAC 02C 0200 Nil!Comilla row Sbrwlards ark!char u
7.Is this a repair to an existing well: =.JYcs or 19 No ..Ti of Mil r,,reed has brew pr.o hied rev the.Ir11 owner.
it this is a repair.fill oar truom well r rsOiiu.ram i,04,nvwirns owl r cplai.l raw narrate of ftlr
repair larder 8!!re nark.m'iiam or on the hail of this force. 23.Site dtarram or additioeal wdl details:
You may use the bawl of this page to preside additional well site details or well
8.Number of well.constructed: 1 construction details. You may also attach additional pages if necessary.
For melriple miter/on Of sal-wad•,apply wells ONLY with taw some enustr,rtiea wax.act
sadnu..ne form. SUBMITTAL INSTLLCTIONS
9.Total wdl depth bc4tm land surface: 25 (ryas 24a. For .411 Wells: Submit this lout within 111 days of completion of well
For martripk wells hsr all depM'Ifdglrers0 rrnimpk-3'ZV0'told 2e'1001 constriction to the following
10.Static water ks el bchrn top of casiuv Ott Division of Water Resources,Information Processing I.nit.
If ease,lee a abort.I.isw;..,•, . 1617 Mail Service('cater,Rakich,NC 27699-1617
II.Borehole diameter:8.25" (ia.) 24b. or Injection Weill ONLY: In addition to sending the form to the address in
2.4aabole. also submit a cope of this form within to days of completion of well
12.Well construction method: USA construction to the follow ing-
eI C..:Il :r.naan. :thlc.direct push etc l
Dhlslou Of Water Resources,Underground tnjectiou Control Program.
FOR WATER SUPPLY WELLS ONI Y: 1636 Mail Service Center.Raleigh,NC 27699-1636
13Y ti odd Ittpml Method attest: 24e.For Water Supply . Injection Wells:
Also submit one copy of this form withal to day s of completion of
13b.Disinfection ts pe: Amount: well construction to the comet health deportment of the county where
constricted
Fenn GW-I Wont,Carob%=D ennriu of Ent itonnnt-tu and Natural Resources-Div emu of Waict Resotrc6 Re.teed.August 20 1