GW1-2021-00322_Well Construction - GW1_20210312

WELL CONSTRUMON RECORD Forttcsma►tlse lldlYs
nib Tenn can be used for sf It or ndfipk wds
1.Welt Contrartor.informatlon:
tai.:.3r'71tR
Will Reyes P� tltl.
A Cxt1lmA+r
1V1411 Cot;sre w Mama rA
4220 ANCWdlComrnnorCcrttbcAiionNtimbcr ICASfNt1TO DfAMtMt TMCKNFBS MAMIAi.SAEDACCO Inc 10 (L 2° e, schedule Opvc
Genpa►ri}`Nmstr
FROM 170 1 DtAA1RMR —THIMM MATCAiAL
2.Well Conxtrnction Permit#: ft, rL tx
t.isr all Rtirahle Writ1w mats ox,Cmrnev.Stir,Varian,IijecGrTl err.) R Q:
3.Well Use(chedc well pxt): t?S
Water Supply Well: FROM I I VIA NVI" I s Tatry, r MAVR. Al
DA6ricultmul 01 unicipal/Pu6lic 10 ft, 20 ft. 2" ►ta 10 schedule Opvc
OCveothemml(rieatingCtoling Supply) C7Residential NR ter Supply(sttagle) R. In
01ndus0iol/Commumial OResidemial Wate>Supply(shated) clto
PROM To MATERL&. fWEACE MIr'iT aWTHOD A AMOUTW
Oirri' "'an 0 ft. 8 ft, Portland poured
Nan-WaterStapply weir: n, rt.
�Mtnritorin C])taaat ,
i ete4otf nett: rt rt.
OAt ttifeF Rcchirp QGMndmttcr
Q M I TO rAl{'R t, � �tPr'� tTVTMt"l!t D
1:7Aqui1er:VomSe and R=ovvy aSalinity Barrier 9 A., 20 ft, sand 2a
13Agnilcr'Test 05to mmtter Dmiftast
DExperimcntnt Tochnology C7Stmsidcncc Control R: rt,
.,'D'Rf1;i TNt{#�)6%�f>ic�'�i8 !ti(riiaT° f�Ith�siM1 =r
OGeothemml MOW Loop) oTracet _PROM TO ID.tSCTtrFflO zsbr 1Mrtncw snaJmck Mmrte
oGeodmanal(HeatingCooling Retum) 00thet IyTtain under#21 Remarks 0 R. 20 (. saporlite
2 ft,
4.Date Wetffs)Completed* 2-4-2021 WdimaMN-12 n. M
So.Well Ineation:
A, ft.
Facnii nlntxrName T•aenity W4(ifappli cbte) R, f!,
v
12701 Lancaster Hwy, Pineville, NC, 28134 ft, (L
Plozica!Add}ess City.and Zip2L R 1 " �• "51
United States d.
C:anen� � 1demlticatiueNb,{PfN)
5h.t ntitilde and t onfiitnde in slmimrtestscainds ordecimalof
��''� 22,Ccrtifientitta:
(It A011 frtkl,mac[Aftfts iS a�dtttl M) cf
35.066365 -80.875821 W ,ir � i a t.�j 2/8/2021
Si�mmtti of Csrsfict'Wen Caiuracicr D
6.1s(src)the Wdi(d): :SPermaneot or oTemporarp B *nM$dRs farm I here63,e, that it.urfus•),00,(w wj ctin orned iirerrommicti
xdth 15A NCAC OX.0100 or I AFCAG 02C.0200 WWI Conpmvdzar Satrrdards and ow a
7.b this a rrpmir to an cxlsting well: OWA or IMP ropy of thir rrrnrd hiwbe o prm'hkd toO Or iW1 a mr,
11ft is o repair..Of oar bwkvi vW1 comtru vlua i%farwrkm artd fKp(aIn the mitre of die
r gwir amlrrt)?1 remarks srrthm or(Mdu beck of r]4ix form. 33.Site diagram or additional Hell detnile:
You may Usb.the back of this page to ptoiide additional ndl site.details or well
8.ANrmber of yetis constructed: 1 raostmedan details,"You may also m acb additional paps if necessafy.
For itwhir4e 14mrW on mm-imer sWpdv rorGs ONLY t+flrh rho wme corrstrarrlloor,.voa easr
iaCo R4WfOrM sllBsinTALmsruenUNs
9.Total welt depth he wiand sutrace: 20' (Q,) ViL t"nr All Wcilm Submit this font witiin 30 dais of Completion(tf-wtll
rarmbfpk W11S lit?01)*pr+te(fdyl�rar ferowto'Je3(K►•acid 2611Rf13 Whitnulian to tht:fol)omtg;
10.Stfitle crater level below tog of easing: 5. {ft,) Division of Water Risourees,Infonnf tino lincessing unit,
tf iron Aryl it aNve evA&use"4" 1617 Alail Senile O Mter,Rak*i b,NC 216",1619
11.Borehole-diameters 6-2-9" 00 RX 10W n V&h ONT X: .ln addition to sending the farm to the adders"in
246 above.also satbmit a copy,of this form,within 30 days of completion of tteil
12 Vifell ct►rtshncttnn nmlhod: sonic crmutiuctlein to the.foltowhW.
(Lc.wow.raaty.cable;diem posh,etc.)
Division of Witter ResooreM Vndettonnd Injim lon Control Program.
FOR WATER SUPPL"WU S ONLY' 1636 ASH Stu,•ice Center,Ratdt .NC 376"-1636
13a.Yidd(gpm) Aldhod of test: 14e.-For WaterSaRplp&iWeation Wethe
Also submit one cog of this fonts atidthin 30 daysofcotpletionof
13h.Dhinf&don type: Amount: `,veil cons n,*on to the county health depattumn of the counly when
onstnacted,
Farm GAr-t Nonh Camlins l7qatin M cf Eadtontnmdt and Mm"Resomm Dhisbn of Alstar Rewnz Rca`scd A.uppst 2013