GW1--05773_Well Construction - GW1_20240926

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WELL CONSTRUCTION RECORD For Internal Usc ONLY:. ' '
This fans can to used Cot single Os tmil'ipk wells
1.Well Contractor Information:
:ti:.%Ye1TtR ZONtS-
Rich Lemire ROM 'TO DESCRIPTION;
tYcll Catgraaor Nantc
ft.' ft.
2593A It. ft
• NC Well Cola/actor CenificatioaNuriher '".15.OtJCER CASING tfor"mnU1Mavediccltsl`OR-LINER(if alipflcablea'•
--- - - nO051 TO DIAMETRRI, I THICKNESS. l MATERIAL"
SAEDACCO ft. It.. ill
• Comp:uty Name .16.INNER CASING OR TUBING(gealhertital ciascd4oate '
• •FROM TO• _ DIAMETER.. ' THICKNESS MATERIAL
2,Welt Constfuednn Permit#: 0 ft. 15 • ft. 2 • ;in.' SCR-40 PVC
tie;al agilit afrle.tn•i1 permits(0.County,Stab;Variarae,fi eakft air.)
"ft. R, 'ha '
3.Weilstise(check wdI"sell 17:SCREEN.
'��'dtor Supply Well:
- -- _ - - • FROM. ' TO . ."Dwlt5TI R 1 SIOTStrl TIIICKNISS • MATRRIAL • .
Cl agncultolal ClMttnicipaliPublic• is It. 25 ft: 2 in :010 SCB-90 PVC
©Geothclmal(Heating'Cooling•Supply) ClResidential Water Supply(single) R, ft In .
DludustriaUContmcrcial ©Residential Water Supply(shred) '"Ts:GROUT- ..
FROM TO. •MATERIAL - EMPIACESIENTMEIIIOD&AMOUNT
❑ittipatian . . ft. ' •ft.
. Non-Water Supply Welty
R.. ft.
®Monitoring DReco ety • . .
-injecllon•Weil:' ft, .- . . .
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t]}1(1111fer Recharge IJG[outlditalcr R.cmcdiallon t9.SANDIGRAVEI.1'ACKfir applicable)" - - . •
Foon' 'Tel' 'MATERIAL ESIPLACt:\1ENTMIt:THOR
l7AgnifcrStorlgc and Recovery • - ASalinity laRlci • • 13 R. 25 ft,. SAND 1t2
ElAgtiifcr Test. :'17Stolm}latcr Drtinage
ft. ft.. •
OEyterimental Technology ❑Sltbsidcncc Control
AO:DRILLING LOG(attach additional sheets ifteccessarvl
OGeothet nal(Closed Loop) .t7Tiicer. .FROM TO DRSCRIPTION(oobr.Uardncn.>,antekitrtx.rransite.out.
17Geodtennal(Heatiii Kaoline Return) Otiher(e plain under A2t Retuaths) 0 It. 25 ft, BROWN PWR•
ft, ff.
4.Date Welts Completed: 9-11-2024 .milt W#SB-2 =
pc�.. . I '' 3-r!
50.Well Location:
(L ft, �+C�y
SDWY 7047 f( 5L j' u• 20.
Facil'uy,'OiincrNnive • Facility h At(iifapplicablc) ft. ft
Ir(,+ :Zap'e l Pr(`rl;.":•Ikvc..t,L,i,_,
306 N. Main St., SPARTA, NC, 28675 R, f1, (4t Qm{
• Pity'si all Address.City.and Zip' 'Ali.RtMARKS
ALLEGIiANY BENTONITE FROM 11' TO 13"
.
Cotrwy Petrel ldcnlikallon NC,(PIN) .
5b.l:atitildc'alid l.ti.ngitude in teegreeslminuteslseetinds or decimal degrees: 22.Certification:
(if welt field,one I.•t1et,g Is snff leiu) �,€/�1
N - ' - NV Cee,e— )'r :c.- 9/14/2024
Sigiulute cif Ccnih!Vial Conttxtor• talc
6.Is(are)the well(s) .oPermaneitt. or Zi CmporatS •
Ny edgnrnb the form,1 hereby certifydiarrtm wet.t.s/mu j is'ov)ants :Ed kr mtirotrlunce
With 1 M MAC 02C.0107 or 15A NCAC 02C.020O Weil Constriction Sraadards and that a
7,Is thin a repair to an ctistiag weir: DYes or "DEN() hair ofdlfr we'll hrrrtn'en ttrarirfed 040 iirll Miller.
lfthfs'Is a rokik fill eat twitvi well carutrucrina itrfurrparion and explain Me mama.of the
repair ruder#21 keniarks ereiian or on the bail of thir form. 23.Site diagram or additional well details:
You may use the back of this page M.provide additional well site details or Welt •
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8.Nmuber of wells constructed: 1 • constmction details. You may also aitacltadditiot(al pages if necessary.. .
For,ttnrdple Ire feciloil or tram-tearer supply wefts ONLY Writ the saute cttnsrrucrlatr,von coo '
samilt oric form. SUBMITTAL iNSTUCTiONS.
9.Total well depth below land surface: 25 • (ly,) 21a. For All Wells:•Submit this"fume within 30•days of completion of Well
Far nrtihlpfe wells list eft deprbs ifdljji•'01;(example-3€'20O•and 2.'010) constmetioll.to die following;
10.Static water level below top of casing: 19 (f,) Division of Water Resau ces,Information Processing Unit,
. lfnrarer level is above casing;axe'+" - - 1617 Mall Service Center,Raleigh,NC 276994617
11.Borehole diameter:8.25" (10 24b.For injection Wells ONLY: in addition to sending the fowl to the.address in
24a above.also.submit a copy of this,font'within 30 days of cotupletion of well
12.1Vell construction method:HSA coustmetion to the following:
(lc:auger.rotary,cable tiitcct push etc.) •
Division of Water Resources,Under vund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Ceittei-.Raleigh,NC 27699.1636
13;o 'VIM(gym) Method of test: ' 21e,For Water Supply&injection Woks:'
Also submit one copy of this fonts.Within 30-days of-completion of -
13b.Disinfection type: • Amount: • well constntctitnl to the calmly hettithl department of the•connty.wberc
constmcted.
Farm GW-I Nosh Carolina IJeporanye n of Eneitonn ent and Natural Resources-•Division of Water ltcxatlr'oes Revised August 2013