GW1-2021-01266_Well Construction - GW1_20210209

WELL CONS MON RECORD l�\� Fwl.radUwOrfr.
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I.WON Cealrateer bdwnmdsc \
Robert Killer M [wmir t
Men Cor,wtr Name; 0. R.
IL
2675 R
NC wee Cowatwe Ccodkoem Number
Ma
SAKDACCO Inc 0 R. 25' d 2• 4 SCR-!0 PVC
C'onpe)Name
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R. R. to
3.Well Us(Fuels well nark
Water Sappy Well: TO I MuKM i SUrf SM IrA
oAgeicullnd p K 251 R. 40• 1L 2• la .010 SCH-40 PVC
OCODO emul(Ho timKookng suppl)) oReademand Wofer Supply(siegk) R. 'L 4
❑bdwriavconuncww oResidmw wren Sappk(shmed) FOOM
ohn 0 R. L- OL Portland/B to
Mae-wmer Supply Welk n.hkkcdm Wen:
❑Agwkr Rcdwpe 00rwdrsaw Reaediriorr
❑AagfR StRag and RtCMln Owsmily Bww 23• R. 40' R. Silica Band 20/30
DAgafe Top 13summwrm Oramew R. a.
ce
ClEapenmemal Technology ossbddm Carty)
o0rot6etmel ICksd l.00pl oTmaer Flum To
O(Goodienowl(Hemallfl7ookag Rome) 00lher qc4Am mader 021 Remeds) 0 R. 24• R. Tm Silt
241 ti 281 R. weathered rock
4.D&W Wd ks)CempINN: 1-21-2021 WdI MOM-1
281 R. ao• R. Tam, silt
Sa.Well Loeaaam: 16 R.
Steven's Killing Co. R. R.
Fs.k)A..oer Noes Faebp IDo(alk)
120 N Main Street, Broadway, NC, 27505
F'a)wal AN..Ca).
Lee Two Ceat bentonita seal from 21'to 231
Cam m, Pard MrmAaelom No IFMI
4k LalWde and tounitede le degealmhimtesM1teomM or dwMW deRraec 2L Ce takadon:
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N W �J•rLx rr 1/24/2021
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6.f.(me)the wtMs)- m►etnfinem ar OTear wwy
A saws as A•w,./Arrrh Yrrgh Yo,ah aTM,I aa.Iwrnl ao:w,nrW w aro,danr
av►l yA NCAC 02C.01fe1,r 1.tA NCAC Ir2C 02M m're Cawmaaoa 5mwWw6 and Ao o
7.b We a rspar in no edFtlq wcN: oyes ter MNe r,q a/da,r .rd A.tarnp.Wd n dr.r11 r,wxr.
ifdw,sarrpmr.pa out lw,wo.vtl.aao,w M.m{on 6.and rplma as,Karr nfA,
-
mad"PI.,t., or u,A.Sort a/dm tarty. .. . 23.She diagram ter addWand wen deeW:
ytilm rmy we the beck of des page to psmide addiooW well we duals m edl
g Member of wellsernrrmtted: 1 2 iemcnaa dunk. You men also aa"additional pegs d memsmry-
F1r as*pk arw,mom w uw-.mn upph:wb,ONLY aah dr err 41
.wawa ear 1sw. MMAffrVAL INMICI20Ne
4.Tmr well dtplb bviaw himd Mfaec 40' yL) '2}L Fwr As WeRa Sabtat dos four within 10 dos o(cmupt of well
Fa,.dspk eve,A.,o0,kpM,Ifd4F,m.,fv.wopk-301M)omd 2 NMI) cmRlmction to the foDming.
le.Steek womw kvel bel esp of east 01.) DirWem of wader Resaerem,hafmmnMm IReteasYgt UdL
IJ+err krrl a Barr reams os"• 1617 Mel Servke Commer.Kok**NC 276WI617
11.Mtelrk dlaeeter:a.2s• (im.l M gar Imkmamw Wells ONLY: In aftwe to seeding de form On the address in
24maboye. also a I a cap of this rotor wbhm y0 dnt of conplamin of evil
12.Wee oweermedw madhod: 4.25• HSA commiumom in the followag.
lie mwr.rme).ogle died Fmk a 1
iNrkkm of water Remmrtm.OmdergreRM lyetfw Cmetfml h.v...
FOR WATER SUPPLY WELLS ONLY: I6M Man So Oke Crme",Ralelgb.NC 274wl6M
tJt Yk4 Wee) Nettled of kee 24e.For Water Soedr At Imlmdom Wells:
Alto submu our oM of ibis form wvhim 10 dn-sof compltaion of
well costnximn to the coma' hwbb depww m of fhe comfy when
_......_.. coomuclod
Fom GW 1 NnnbCawhm Deparmem of Em manrmt ad Nowal Rem.wae-Dpwom of Warr Remus M.wd my 201i