GW1-2021-00319_Well Construction - GW1_20210312

f WELL CONSI UMON RECORD /�, For(rs nw Use ONLY;
'tarns foma can be esed for single tK amttiple%%ells \ `/
1.Vial Gontmetor Infortnallon:
Robert Miller pR M 7p DrSGltiPrl Y
W401 CoMti'netoi N2ft
ft, fi;
2675
WC Wdl COntmetorOn irkm ion Manton ,i.�Otl f R.t`A` t3 qloot1NliR
FROM 170 01.01um Tt1rCb TM 'MAMtf1Ar.
SABDACCO Inc 0 (t. 33' fL 6" e. SCE-40 PVC
Cotgw)•$arse 16a1 1t.
FROM TO L%AIr.TBR. 1i11CANaSS I MATT"
2,Wegl0Dn.%troc09nPcrrnll#. WM0301096 0 IL 37' f1. 2" &► SCE-40 PVC
listall oppurabtr urfl_perr.,us(ie;Gauary,swot VarizWe.lil4ruerf eir.)
ft.
3.Wdi,Use(cbeck wellvkY
FROM To _0701rTF.R - .OT 173: 1st MAYRRAAt,
L7A�egalttrtt►l t7 unicip tg1tiblic 37' R. 47' ft. 2" la .010 SCH-40{
Water$nppl}oRdl: y PVC
DGeotitemlal(ReatingCooligg Supply) QResidentiai Wa r Supply ttsingl8) R. I ft, is
Olndusnial/Gontrptereial QResidentntl Water Suppiq(shnned) 31:QROt}T F
YROM TO MATBR1Ai. EMP'fACZifiiF�Q'rMoiMm myr.
Q1tti` lion 0 ft. 33' fl. Portland/Be mike
Nan-Water Supply Well: 0 ft. 33' ft. Portland/Be Tmeite
®tvlonitorin QRtxa�s
njertlotr!Well: h; ft.
QAgttifcrRcclpaf� OGtoutidn�vtclrRetrtedialion !t5:' ,` 1t�CtY�: l: .' ,_� h - .
nit
❑AquifcrSrotBge and Rcco'.Im QSalinityDarricr 47' ft. Silica Sand 20/30
QAquifer7crA QStomm•RterDron$ge 0L
0l5Vcrin=tai Tochnolog Wabsidencc CvMl
2n.-n1tn2aS t � atr� ,; ttt,...
QGeothentml(Closed Loop) QTracer oROH ltf 10 cttlrlfas ambwNn sA4!rbck
OGaotiientual ea" Retnm QOther 'nunder#21Remaft 0 fV 25' tt. Tan Silt
25' R. 47' ft. Rock
�.DateiYetJG$)Cbnrpl¢ted; 2-26-2021 Wd1IDNMw-21 �"
,,,-,
Ss.'1'ireil Locatihpn: R.
Orion Oaks Mobile Home Park A, ft � J
FscOity/Owner Mmne Facility TD#(if Wpii lc)
7098 Fox Ct., Gastonia, NC, 28052 g,
•.n Co;.ti(t.l
P24izicot Address.City,and Zip `j
].d 3tl iNAItKS - 'i
Gaston Two feet bentonite seal from 33' to 35'
O mdly barest tdeaiitimlion No,(PW) F�
Sh.1.Rtititdcand#�in ltipde in d ccltnimrtt lsetondsorcTccirtr l dt rocs: 22.ctrti!`x"tion:
(itwoltieWonelalllpr 38#rtfilcictd)
W 3/1/2021
5igrrstoteof "�-.tea. Dam
6.h(Qe)U1e vvell($): gVermanent or LYiemporrarp Ay-A
8On&this fetiar,f lrtetidry^e'errtfj rhsrt ttJr mrlJjs9 ftal(+rscJ ncmsYnitiM to+>ticcarrtdaii�r
with M NGAC 02C,4 w or 154 ArCAC 02C;0200 BleilComirwWoa Snrrefinela andAWs a
7.Le't1[ts A rquair"to an C"ng weir: OV" or W N() COPY s0th mrn rt fins born gm'wm to l(v nrll moaner.
if altls fsrr re'pdr.flll ads kmftw ruell mnuaavtaw i jormnrlon anti ewfabi the mrRre of dfi,
Almir wider 021 rnmrksxr 60,or an flit b4k of thufarm 23.Site dinram.or additional wtfl demlls:
You ma}'use the.back of this page to pfmide additional Wail site-details or mli
$.N otnber of��°etis cotlstntr#ed` 1 eonshuction details. You may also attach additional pages if Ussery.
For mutriple,lirfce kviOrxfen-»met'sW*KWhONLYnfrltthrsameeu)TspwrAM.yvaawn 1LBMI� i j;VC #,i lV�
sabstat me form r +.
9.Total Welt depth below laud slufaeft 47 111,) 24a Por Alt Wellk Submit this fans uilhih 16 d4t of Obnrp(etion of Oe1l
f ar Mlltlfple MYtIE list all dr�rks tlf�l ttN!(P.UM1Pl fire't 2 1`Q ll$ 1 ) construction to the fotion71g:
10.Ststic.+r ater letr16elow top of casino (n,) Dfit`islon of Water Resource$,Information Ptroata.$ting(Taft,
tf writer level is dbove a ada g,air"+" 1617 Muil'Ser•rice Crater,Rate*KC 27609 3617
11.gotvholc distneter:10.25"/6" (ln) 24b.Ent infection No ONLY. 1n addition to sending fire form to the address in
24a aWv- also submit a.copy of this fbmr vrithin 30 days of completion of WJI
12,VVdi cortstrneflatt Mdbod:HSA/Air conmetiontotheWowing:
(i.e.der rot my,cables din Ct pnslL etc:) Dh'Lsion of Water Itesourem.Vndergrouud Infectlon Control mgmm.
FOR NVATFR SUPPLY WELLS ONLY: 1636 Mgfl Stu ice Center.RaldO,NC 276"-1636'
13a.Vidd(gpm) Method of test 23c.For Water SoR&fie pjoattoo Wells:
Also submit one copy of this form mithin 30 daysofcoinnpietionof
13b.Disinfection hype: Amount: well construction to the county health department of the counlc When:
constmaod.
Farm GW-I North Carolina Dgdntmcnt of Fm-fronanem and Wnaal Pmnrccs-.Division oMlincrite> Rn iscd Au�►r5t 2013