GW1--05854_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD For Iits-rrur I ..•FIN N.
This Fonnean bc used for sinpk or nit0ipk acllk
I.Well Contractor Information:
14.WATIIR ZONES
Tyler Brown IKON m DOS('itIP111iN
Welt('nnricaot h ink h. ft,
4625A h, ft, I
NC Well Commctor C cn ifnat roux b.n ni c r 115.OtriFR CASING dor multi-cased eclhj OR LINER I if a!ptkal#41
i FpON } TO DIANrTTR TKK"K�T'e NI%TITO kl
SAEDACCO 0 ft. 10 ft. 1 In. SCH-40 PVC
('t,aq),la, \.,,,w le.INNER CASING OR TUBING thermal dnMisll
InOM TO DIAMETER THICKNESS NI tit RI tl.
2.Well Construction Permit 4: ft. ft. Is.
L❑di apphi ublr wrrlpronits it r.County.Shoe.lStnarev.lrhaYial At i
h. fG Is.
3.WdI Use(check well use': 17.SCRfZN -
Water Suppl Well: , mom TO DIAMETER alDTSin TNKTLNItt$ MATRRIAI.
0Agtr:uttUral DMunicipal•Public 10 R. 20 It 1 ia• .010 SCH-40 PVC
DGeothemlal(Heating+Cooling Supply) OResideinial Water Supply(single, h' h i`
la GROUT I
DhldusttiaUComnscrcial DRcsidentral Water Supply(shoed ,,;;1rI 11I _ MATERIAL. EtRLACEMENT stetson aAMOUNT
❑Rogation II, rt.
Non-Water Supply Well: n n,
Eklolutonne ❑Rccos err
Injection Well: It. n.
❑Aquifer Recharge ❑Groundw;ater Remediatioe I9.SANDr(.k11 It.PACK Ofap_Y__M_)
FROM II, a MATRIUI. RMPt.ACKVENTMFTMOO
0Aquifer Storage and Rccmen' ❑Salinity Barrier h, ft,
❑Aquifer Test ❑Stomm:acr Drainage h. h,
❑FtTscnmcntalTahnnlo)h ❑Ssbsldcnc('nnml 2a.DRI1,IING LOG hesesYYwW shoats ifsceessanI
OGeotllennal(Closed Loop) ❑Tracer FROM to DrsCRw►noNochrehmdums,warsLnpr.Rrea+n•rk-1
❑Geoihennal IHeaung"C'uoliis Return) DOther(esplam under 021 kctnad,si 1 h- h• __
ft. ft.
I
4.Date Well(s)Completed: 9-5-24 Wt31IDuTMW-12 `�'^ 7 Li
5a.Well Location: ft. ft. Off U 1 2024
Fuquay-Varina Elementary School ft. ILI ;l.ta(( a-4-,-, I
FacilityOa nor Name Faclrnr IDM(ifapplicabk) �}
fl. R.
6600 Johnson Pond Rd., Fuquay-Varina, NC, 27526 n. ' fr.'
Pln scat address,Cm.and Z) IL Rithim ILs - -
Wake Temporary well for grab groundwater sample
I;nnnr P n:el Idenldf'-ilia,n No IPls:i
Sh.Latitude and I.nngitudc in deg ecs'minutec,orennda nr decimal degrees: 22.('ertificatioa:
or sell field,raw lat.ton is suftkkull
N W n /tio �" 5-z 9/9/2024
Sid of Castled Well Contractor Disc
6.Is laic!the welllsi: Pennnrcnt or 7LTrmpr,ran M signing dru hare.I hereby i-errtfr this the rrwlb.+t won incrrl comma-red or araoMnnte
�r/� with I SA NC.4C 02C,O/00 or 15A NCAC 02C.02(W Well Cwterar nonSaaaiorrla and rhos a
l'7.Is this a repair to an existing well: Lilies or KNo nrvv ofdtir moor./hat hero pnn'trkd to the rrr•N owner.
if this it o rehear.fill urat tnarna Neil,(NW oar Iron lnloraarraur oarl a rplirn the nowt-of lhr
repair under S21 remarks xrclao.,or on the hock of Mix faun. 23.Site diagram or additional well details:
You mar rise the back of this page to pros Kh additional well site details or well
8.Number of welly constructed: 1 consttucYiun details. You into also attach additional pages if necessary.
For noWrlpk rafer•ri al Of nrat-»rarer rupph wells 011.11 war/a the same rowsersartfan ‘,...a a-,.o
wAutir erne homer. SLIBMITTAl.INSTUCTIONS
9.Tetal well depth beiow lard surfaces 20 (11,1 24a. For All Welly Submit this fann within i(I days of completion of well
For maltiplr weds liu all r/rpdrr if alrPerrot rerarupfe-3.200'and 2R-(0(1) constmctlon to the following-
lit.t.Static water level below top of caving: (h•) Dh-isiun of Water Resources,Information Processing I nit.
fr a;rOrr h.,rl n ahem•t o,atx.av • 1617 Mail Service('cater,Raleigh,N('27699-1617
I I.Borehole diameter:2.25" (ice) 24b.For Injection Wells ONI.Y: In addition to sending the form to the address in
24a abol e. also submit a copy of this form within Z) days of completion of well
12,Well coontrncti n method: DPT coital ruction to the following.
li c.auger.roan.cable.direct push:I.
phision of Water Resources.l ndergroond Injection Control Pnigram,
FOR WATER SUPPLY WELLS()NI 1: 1636 Mall Service Center.Rakish.NC 2 7699-1636
13a Vivid ti pml �Ir Ihnd of test
24c.For Water Supply K Injection Wells:
Also submit one cops of this form roithen ;it dies of coiriplelioni of
Idly.Disinfection type: \nnutl: well consmunan to the county health department of the counts orlon
• constructed
Form GW-1 North Carolina['gunmen'of Ern nomrwal aol Natural Resources-Unxtoo of Water Rmotrtm her Iced Aigust 201.1