GW1--06055_Well Construction - GW1_20241011

1 .
I,• . 1 I . .
WELL CONSTRUCTION RECORD b\\"'D Per Trectua!Ike g/Nj.:1; ,
TUN form can bc used fir.single or multiple wells'. '
I . .
I.Well COntractor Information:
14:-WATER ZONES
' Tyler Brown . . - FROM ' TO DESCRIPTION 1 •
. . . .
Well.Ctultuclot Norge ft. It,
rt. .
1 !.
4625 : •
NC Will Conlrectircatilleatioti Muth& . . AS.OUTER:CASING(fit ratuttl-disethiellst OR-LINER(Ifitil leatk)t
- - FROM To - DIAMETER. THICKNESS- .: TTATERIAL.
. . .
SAEDACCO - • - 'fit- IL . In.,
- •
' CompaniNome- • .16.INNERCASING OR TUBING(geothermal dosed-loop).•-:,-
• -FROM • TO DIAMETER' : THICKNESS MATERIAL
. .
2,Well ConStruction Penult tit - . - 0 , ft. 10 ' ft. 2 la.) SCR-40 PVC
list all aFplioatde Wrilpehnies,O,C.COWIfy;Striti7,..Vaelairce..Ilecticel.elc..k
. .ft ft. i=,.'' • '
3.Welttise(ehecIr well 054: • • - 17,SCREEN • ,
_-
FROM.- . 10 •DIAMETER st,OTE171. THICENtiiS matt:atm.
Water Supply Well: - . 10 ft. 20. -ft. 2 1II. 1 ,010 SCH-40. PVC
DAgikultinal .CIMunidipaliPublig .
,
rt. its ,
EIGeothetrnal(lleatingiCobiing Supply), °Residential Water Supply(single) .'r4 . . .
- -. . ..
Oludustrial/Comnicrcial °Residential Water Supply(shared) •
IIIGROUT OM • -. .TO- • . .MATERIAL • - EmPEAcLMEN. T METH on&AmotiNT
Ofttigation . , . .
. . . -. 0 ' .ft, 6 : It. Portland . pour
Neu-Water SuPplY Welt:- f ' • - . .
.
• It. ' ft.
liMonitoring - .-PRecoyety .
. . . . .
Inject lon'Well:- -' .
• •. , •ft. -
. .
°Aquifer Recharge' • Caditimichsit. Icr RattediatiOn• ' 2/9:SAND/GRAVELPACK(if upulleabler,
. . , .. . FROM —10' SIATRIHAI.1 • RBI PLACEMENT MF:THOR
- °Aquifer Storage and Reeovity : °Salinity Da.irici . ' 8 ft:. 20 ft. Sand 1' • 2
. . °Aquifer Test. PStormsvater Drainage- , .
.1t. ft. • , .
nExperiniental Technology °SubsidenceColt-of- . -
-In:DRILLING-LOG ratlach-additiorial steel II accessarvl • .
OGeotkerniaL(Closed Loop) . . Canker. . FROM ' TO • • : DESCRIPTIM kobr.lianinei,sianick Opt.gyain Ate.de.)
. DGeotheimal(FleatingiCabline Return) . °Other(explain under#21 Rewaths) • .-tt. rt. • - • •
ft.. - rt..
4.ritti6 WeU(s)ComPletii: 9/6/24 ' • Well ID I4T4-1
,, - . -
•
IL. . rt. • <,..", '4,11;714
Sa.Well Location: . . .
ft.' 11.
Former AlamanceOarbage ' . . ft,' : : OCT 1 .1. 2024 • .
Fa.city,Clirnorl‘bow ' . Feedity7.01;(ifapplicable)
R,' . rt. ;liff::::.7,1;i4e.c-:-1 7' . , ;lje
3479 Danieley Water Wheel Rd., Burlington, NC, 27217_ .11. It.
.PlOiCal Atidicts,.city.and Zip- s2t;R4mARKs: . . , .
•A Bentonite seal from 6-114 . •larnance . .. .
.
" ' '
, - l'AMOI Id:31iiINI No,(PIN) . ,
. , . .
. . . •.
51),Latittide arid Longitude hi ttegreesfminuteii.seconds rirtteeitnal degrieg 22.Certifieation:'
(if Sell Aoki,one.10104 is mtllokso •
•N . W i. 0.-.--z----7--- 9/26/2024=
' ' • SitiC3ituAi Of Ccitilkd Well Conlractai ! ' pale •
6.•Is(an.)the wen* IDPermanent...or- pTenitiordry
lty sigaPig.dels hum I herd.;Criltfy that the we.110,1 wm(srn.I crisinrcrat LI?accordance
. ,
. . with 15A NCACO2C.0100 or/.TA NCAC'1',,2C.0200 Well Com/nee/km Srorida,ds and Ma:d
7,Is this a Ttpair to an existing well; °Ycs or 'BIM) •rosty'of Mir ronird bay been pmyitted to dv),Irli owner,
If WM a iepair.fil1 oat kritinii well coositurtioa inforrnarion and explain the nature of the • • ' • .
• repairrarder e21 irtnarks'Woiiin.fieigi the hail Of thii form. 23.Site Cliagram-or additional well details:
. ' You.may_ute the back of this page'to provide additional sell site details or(tell
S.Nuntherof Wells constructed: 1 • • - . cousin:ern:1i details. You;nay also attach additional pages if nixes:taw.
For malriple
. r*Jlif 611C IVlITtSleioJ1.if uo-urrer supply.rerONLY with die moor construitIon,.yol'aria
S L , . .
SUBMITTAL INSTUCTIONS' .
. ., .
9:Total well 20depth below land surface; (ft) 24a, Far Al Weibil•Submit this fain;within Stl•days of completion of well
For nuihipie levels-fly all ilepthy if dire rill;( attripie-3E,2011'aW12@ WO) ' . constiumion to the following:
,- •
10.Static water level below top of casing: 'A) Divition of Water Resnu ices,mfitrination'Prnecssing Unit,
If irdiet level is above easfag:ase"4." - • 1617 Mail Service Center,Raleigh,NC 236991.617
IL Borehole diameter:8•25" - lin.) 24b.For'lliketion Wells ONLY: ha addition to sending the fonn to the,address in
,
, 24dabove.also submit a copy of this foritt within SO-days of completion.of well
12.Well construction'method:RSA roost:action to the following:
(Lc.auger.rbiary,cable.direct pink (c.). • . ' . • •
Division of Water Resources,Underground Injection Controlr Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 276994636
• . t :
24e.-For-Water Supply&Injection Wills;
14a.Vichl(glint) Method of teSt:
' Also subtidt one,copy of this pink within 30.days Of Completion of.•
1311.Disinfection typiu • Amount: , well consttuction to the county health department of the.county.where
-
constrnctect
1 , •
FortuGAL 1 North Catalina Dgrartutcut of Enriumnrrit aid Natural Resources-Division of Water Rm,cnt-ces Revised August 2013