GW1-2021-01201_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD for litcnml Use ONLY:
Ms form con be uwd far sivgk ar maltipk wells
1.W'dI Contractor information:
14.WATER ZONM
Robert Miller FRt)M I m%CHIMON
1Vdl 4'nrgrldnr game ft. rt.
2675
ft. rt.
NCRreB Contractor CcnificalionNtmrber I5.0[ffER_GASINGtrat.411{hiFasnfncFls'pR1;1NER{ira tleabtrJ
FRO r1 Tt7 DIAMETER THICKNEss AIATERTAL
SAEDACCO Inc 0 (L 30, (L 2" ie. SCH-40 PVC
(:trngrui)'Naetc m.IIV,VE#C'GACI7VG OR TUBING t eat6ennsl dowd+xioll
_
FROM TO DthdtFTER THICKNESS AIAWMAL
2,W'dl Construction Petmft ft. ft. h
Ulf all applimble wi-11 permits ti_r..County.Sraar,lanrinmer.froc ca Poi-.) ft. ft.
3.Wd t Usk(chesti well u sc)
Water Supltlti�VPell: _ FROM TO WAIMPTFIt StATSIM T1f1(yCt1V$$ 1MATKR1A1,
GIAgrkuhural Clhi)tTricipol, ltblic 30' It. 45' fl: 2 in. 010 SCH-46 PVC
OCeothenw-1(rleadnocoling Supply) OItesidential Water Supply(single) ft. ft. In
®industri l/Conimcrcial ®Residential Water Suppy'(sl md) Is,GROUT
1rAOA! TO I ztATEMAL I IMPLAC4v'1ENT11rlTHOD&AMOl1NT
❑hri xlion 0 ft. 26' (L Portland/Beat mkhte
Non-Water Supply Weil:
COMonitorinG ❑Rc€N�r rt. rL
Injection Weli: ft. (L
0Aquifer Rccharg,e QGrourtdwater Rcuicclialion 19.SAN5KGRAV1:L PAC1iri appileatotei
rR ,rt f(rI MATERIAL. s)ri A tr_ t'srL7tt n�
❑Ailuifcr Storage and Recovery OSalinity Sarrier 28, ft. 45' A. Silica Sand 20/30
❑Aquifer Test ❑Sionroxmer Druinaw
❑E\perimcntal Ttxbnology ❑Subsidcncc Contirol
2(1:DR.IIA NG LOGYsllsch.aildifinnal aheelsi(uccescxn
❑Geoiltenital(Closed Loop) ❑Tracer .FROM TO pFSCRrpT10\vsbr,hArdflitt mlivei utf r nSW'60
❑Goothetrital fHeatil fooli 22 Retim)) ❑Other l � lain Under#21 Rema&) 0 (L 45' (L Tan Silty sand
4.Date Well(s)Completed: 1-5-2021 FWdl,1D#MW-2R
ft. (L
5a V!'€li Lticataln: n,
Dallas Food Mart rt. (L
Facilhy)0,n•ncrNorae Facilh)-1Dk(if applicable) A. ft,
2294 Smokey Park Hwy , Candler, NC, 28715
IL rL
Plrn'sicul Address.Cih'.and Zip -2 t.RCMAllt{,S
Buncombe Two feet bentonite seal from 261TO 28'
Part•tl Idunfirka.1 ion Na,(PIN)
NIP.I'arihule and Longitude in dcgrt r4mirrutcslsccrinds nr decimal dcgrees: 22.('crtifieatinn:
(Itmali tlitld,Gott L•ulottIg sufficietd")
1/7/2021
Dale
6.IS(are)tire well(s): xPernianent or ❑Temimlrar) 9 '�.�
Stga3tulr of �'.;x�F 1' �,,.:...•:'::
,, i9 . Hy'srgninl Ih r form 1 heresy rerri(e fhtaf Ike 7{r11(.k){1YlY{yy ry 1[fnr3rrui'letl it?rPLY'0r 01anCe
at h 15A AVAC 02C.01 M ar 1JA ArCAC 02C.031i0 Well rnlrsymatnit stiaWartts and darn a
7.Is this-a repair to an existing welE ❑Yes tlr Far r epy ni rhit reconi has bee snot irdr4l rev Ad-mrll mrr{er.
11 rhis is a rePt kfiilllnYr tmtr{P9 ivell cemrsrnmfnn inforrmrlrn{mud rxplwi the n(e I�21
repair umlerS21 rranarks.rectian or fin the bra l tltAk JEnnr. o v 23.Site diagram or additional well detnits:
SG9l��1W11 may use tube back of this page to provide additional well site details or ivell
8.Number of wells constructed: c:onstluction details. You ina.v also attach additional pages if lwvessary-
For/malddrleInjeei witynmi-itwrerragt.ywrihONLY,00,
Nu nrit arlr form. SUBMITTAL INCT T.TIONS
9.Total wdI depth below land surface: 451 (fi.) 24a. For Ail )Wills: Submit this font within 30 dips of completion of uvell
For nim0pdr wells liar a0,+0p*s 1 rd4 rertr(ramrrrfe-J@2077'and 2e tt,40'1 construction to lute foltoning.
10.Static water level below top of casing: (ft.) Dig 6km of Water Resources,information Processing Unit,
1f welter hurl is ahuve castrtg,&M"a" 1617 Mail Service Center.Ralcigh,,NC 2 76 99-1 6 1 7
al.Borehole diameter:8.25 (in,) 24b.Ear Iniagart Wells ONLY: in addition to sending the forrn to the address in
24a above. also subrnit a copy of this form within 30 days of completion of well
12,Wrell constrtiction frTetbad' 4.25" HSA txonstntcliorl to the followfike_
(i.e.augcr.mute}•.cable.dinYi paslt etc.)
Division of Water Resoto rem Underground Injection Coo mrolProgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 276994636
13a.Vidd(upm) McIt Lod of test: 24c.For Water Supply&injection Wells:
Also sub6i t one coin' of this form %vilhin 30 days of.completion of
13b.Diilurktion t'Vt ._.-_.._- _. Amount wcll constriction to the county hcrolth dcpailm rrl of the anent.•where
€onsinictcd,
Farm G%Ar-t Nonb Camllna DcPcmntent of$m'im roll l and Nawral Resources-Dh;.ion of N%rater Rmuro 5 Remised August 201.1