GW1--05855_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD Fat inacrnollIscONLY:
Tins form can be mod for singk or mull Mk twits
1.Well Contractor Information:
14,WATER ZONES
Tyler Brown P1OM TO DESCRIPTION
Well Contractor Name ft. ft
4625A ft. ft.
NC Well CamtacforCcnification Number IS,OUTER CASING(fur multi-eased wens)OR LINER Of aepieaNy
'MOM TO DI MrtFit TMK'KNTcI 14ATE1tAL
SAEDACCO 0 ft. 10 ft. 1 ta. SCH-40 PVC
('oayt:u)N.mtt: . IC INNER CASING OR TURING igtalYerasai dwisaiso!1
FROM 10 _D I(DIAMETER THkNESS MATERIAL
2.Well('onstruction Permit il: n. I ft. in.
Liu aft aplali,nhlr well permits(i.e.County.Sdarr,Variance..)Otaut)rte.t --- _.._-- i
ft. j rc in.
3.Well Coe(check well use): ----___"-
17.S('REtN
Water Supply Well: PItOM TO b1AMP:TPA *IOt ill TRKTOONS MATPaAI.
UAgrtcultural OMunicipal/Public 10 ft. 20 R. 1 030 SCB-40 PVC
OGeothemtal IHeating.Cooling Supply) OResiderttial Water Supply(single) rt. ft is
OhldustriaVCommercial OResidential Water Supply(stetted) 111.000,4 U
PROM T TO MATERIAL EMPLACEMENT METHOD 4 AMOUNT .
❑lmpation ft. ti
Non-Water Supple Welt: ft, •
RMonitonnc ❑Recover
IrJection Well: ft. ft.
❑Aquifer Recharge ❑C3mundwaterRemcdiation 19.SANDDGRAVRL PACK Ofttp/ieaMel
• WHOM TO MAT11IAn. e:HPH.A(r\MF\t MEtn0n
❑Aquifer Storage and Rccos'ety °Salinity Barrier ft. ft,
❑Aquifer Test OSlormnaacr Drainage ft. It
OExpcnnental tozhnology ❑Sabsidcrcc Control
2n,DRILLING LOG tat@ad atd1lMluaatsheets if wormers I
OGeothennal(Closed Loop OTtaett PROM TO , OPSCRIPIlON t.LLI%hedisc..,..awwL opt.gala.r.•.(e I
IGeothenfal lHeaung.Cooline Return) tO ther(explain under#2 I Remarks) ft. ft.
R. ft.
1.Date Well(s)Completed: 9-4-24 _W'dl ID*TMW-9 - .• .
r4 ft. I_
Sat.Well Location: ft ft.
Fuquay-Varina Elementary School ft. ft. OCT V.1 1 2024
Factlii.'OitierName Facility IDti(if applicable) ft. ' ftilioiiiivrIt,,
6600 Johnson Pond Rd., Fuquay-Varina, NC, 27526 ft. ft. �" {T 'F�'". rJs6
Pln sical Address.Cit).and Zip • 21,RLMARKS
Wake ' Temporary well for grab groundwater sample
('anWr PrttelMemdeitionNo IPINt
Sh.Latitude and Longitude in nkgiecsi infirm trs.Seenndsnr decimal degrees:s: 22.('ertifrcati a:
(Ifwcll field,one kWlagg t•.••ull,...:u�
N R' --z-----11` 9/9/2024
Signatu.of Certified Well Connector Dole
O.Is tare)the wellls): '-1Pettnanent or R'Tempinrary In signing thu form,1 herein.certify that ilie wel(sl liar(weir)cwartnn•red or error aneC
with 154 NCAC(12C,O/00 or 15A NCAC 02C.0200 Weil Consere Gnat Sklalard I a,,A char.r
7.Ls this a repair to an etistiag well: D'es or KIND r.ap.of chit record has hrr+t provided to sib•well mow.
If alas it a repair,(ll.at ttmaww wril,.m•Unln lion tnfrlrm4orto't drnl a plain rlw Iprrere of tits
repair ander 021 rreuarla ve.9nan or rv,rhe hark of chi.,firm. 23.Site diagram or additional well details:
Yon may use the back of this page to pins ode additional well site details or well
S.Number of wells coasenseted: 1 con sinuction details. You lint also attach additional pages if necessary.
For main,*nt}evrhrtt i.e maw-Wass,u(pl.Weill OiN1.1 wait rho some rIms(rlrrti.m s,.a"tr.
sNWwif oner..rw. MIRMITTAI LNSTUCTIONS
9.Taal well depth be oo land surface: 20 (fl,) 24a. For All Wells: Suhrml this farm within 10 days of completion of well
Far mn)Irplr well,list toll droll r/de i rend(e:rdmipfr-3.*200 dull.5 J4Nfl conslntction to the followi tip
le.Static water Iesel hello top of casl.V (ft.) Division of Water Resources,Information Processing knit.
Ifwater 1c,el n ohm.r.uw;.ra•,• + 1617 Mail Sen-ice fearer,Raleigh,N('27699-1617
I1.Borehole diameter:2.25" Do.) 21b.For Inj):ction Weib ONLY: In addition to sending the form to the address in
21aabme. also submit a copy of this form within z0 days of completion of well
12.Well eunstrswtinn method:DPT cotufntction to the folloning.
it c.sa_rr.r{van.cask.direct push.etc.t
Division of Water Resources.Underground tnjcetion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1634 Mail Service Center.Raleigh.NC 27099.I636
24e.For V. Nupt)h X Inju-itiun%%ells:
134 1 it.ld(gpni) 'Method oftest:
Also submit one copy of this form wTulin .o dessof completion of
13b.DisinfectionAmorist: well construction to the county health department of the county where
tvpl� coiishttctcd
Form GW-I North Carolina Dgpannrnt of Em unrutt7u and Natural Resources-Un iron of Wafer Resotrces N.s u.d August Nt I 1