GW1-2021-01237_Well Construction - GW1_20210209

WELL C❑NSTRUC110N RECORD For[Wrrml Use ONLY:
Tins rprtncon he used farsingIr-or mrillipie ne[Is
•
1.WelI Contractor Fnformatlon:
14.SVATPR ZONES
Will Keyes I FROuf I TO I DFSf'RIPl-JQN
1V01 Cvntrctpr Name
fl. rl.
4220 A rat. fta
t5.OUTER CAS GG itnr nlii aiNCWcll Cofdractor Certification N11mber Td 680s RLINRifa cobtel
e {
111 T nv+x MATERIAL
SAEDACCO Inc 0 ft, 14' (L 2" im SCE-40 PVC
(:rnegivey Name 16,1NNER CASING'OR TUBING itientherrnal clo ged-lrxr
FROM TO D1,01F-TER THICKNEss Yi,41ERIAL
2,Well Con53ruction Permit ft. ff. iut.
list rrll eppilir lble reel!Immits ri_e.County,3tutr,l+nrinrerr,Ifordon eve-.J
ft. fi, in.
3.Wei Ifrrc(k*kwell use):
Water Supplr.°Well:
- FROM I TO I p1ANTMItt I SLAT$17ar 1T nC-W TZS I MArrRtAI,
❑Apiculturil 0muln,icipalipublic 14' ft. 39' (t. 2" irk oldSCH-40 PVC
CC*othenm. l(Heating/Cooling Supply) DResidential Water Snpph'(single) tL fL
©tndustrialfCommercial ©Residential Water Smpph•(shared) 18:GROUT
FROM TO MATERE L I VKPLACEWWLNT 14£rr1OD d AMOUNT
131mi ation 0 ft. 10' fL Portland poured
Non-Water Supply Well: tl. rL
mmonitoring ❑Rccavrt},
injection Well:
13Aquifer Rcchuge 00roundwalcr Rcmcdiation 19.SANDCRAVLL PAMitf t i'Ircable
" " LIP _ Am'Tr,ium, _ _ CiA]t'tall�i�iF:\THFst•11 n -_..
❑Ailuifcr Sloragc anti Recovrry ❑Salinity Barticf 12 ft. 39' ft, sand 3a
❑Aquifer Tcst ❑Siortnwater DmIrlam
❑E.xpetimcnhal Technola�• ❑Subsidence Control
2f1.,DRll Nk G LOG(attach arddifionrii slrecftif rteccRWrn
❑G.othennal(ClosedLoop) ❑Tracer FROM TO PESCRIMON, txiFsr,1hardtrt:4i 5tr4,mf is nc4+e<tcl
❑Geothenwil(Hestif e1C0olft3e Retunf) ❑Other f ainUnder#21 Retrafis) 0 (L 37' (L saporlite
37' ft. 39' (L bed rock
4.Date Well(s)Cotnpleled; 1-13-21 Wdl ID#EW-3
rat. rL
Sa Well laticathin: fL fL
Wells Hosiery Mills fL tL
Fac110yY0tvncrNontc Faclity]DR(if applicable) pa ft.
1758 S. Fayetteville St., Asheboro, KC, 27205 ft. ft.
Plnsicai Address.City.surd Zip =,21:RI:MA1tf:S
Randolph Bentonite seal: 10-12'
(:rrntth' PAtsel Id-zn1il`tcallion No.(MN;I
5b.iAtihldc and Longitude in dcgrr;eslminutcslscconds or decim it degrees: 22.Certification:
Of Hell field,cure l:iihort i8 smWiicicrd)
35.681414 N -79.821353 1/18/2021
Sigavurt cf Ccfiiiics"Well Coutnrctor Date
6.iS(aroi)the well(x): xPernianent or ❑Temporamy hN s;getinp,ehlrr fiorm,1 hereby rerrrfv th(ar wire irrlurr was finrm)crnurnwmd kr m-cerdance,
u•irh I&t NCAC 02*C.01W or 15A h10tC rJ-X,r1:tl0 Well Consrrncrron Sraruyarrrs curd Am era
7.Ls this a repair to an existing well: ElVes or KNo r�r�J ntrrliit reroni lure bra'err/r„rir&d ran rah, rrti rrrmnrl r.
lfrhrs If a re;*11r,fill rxvrkamm etr!l arW a plah the norpre of rrrr
rer_air raider$21 remarks rare-ian ew un the bful erthi-s form. 23.Site diagram or additional Well details:
You may use die bacl;of this pax to provide additional well,site deuils or well
8.Tnrnber of Wells ctlnstrrteted: cUnsI etion details. You Ina.'also attach addititnal pages if necessary.
For mailrrrJr 1q}errh�r,H arNr-nxrrFr pf)rrr!!z Di�'l,t'rrlrlr rlir'�#rfira1a�r,y�uZrrt`
submit am farts. SUBMITTAL INSTUCT7ONS
9.Total well depth below land surface: 39 �''r_l� X 9 20 .) 24. to,Atl Neils: Sutlnul this.faun is`illin 30 daps of completion of hell
par Aft0iplr Wells Ksr aU dePAT Vdif-erent <r+qt 2@ KA't �t �`�
12 fc n5lnfation In the following:
�fi vflr s,?r l'l Yi-n n� r'�:J L3st I ,
10.Static Water level below top of casinr,,: � E �rjQi�.) Divivian of Alter Fee%au roes,tnformatiou Processing Unit.
Ifnatet level ds rdlove rasing,am"+" 14517 Mail Service(.enter.,R:ticigh,NC 2769'I-1617
11.Borehole diamctev 4" (ia) 24h.Far iniceNon Wells ONLti': in addition to sending the faun to die addrm in
24a above. also submit a copy of this forte within 30 dan's of completion of well
12,Well convTr "ion method: sonic construction totlw following:
(i-c.auger.rotary,cable.direct push ctc.)
DF<'fslafl of Water Resources.Underground iltjcrtitllf Control Plrlgraln,
FOR WATER SGPPLV WELLS ONLY: 1636 ALM Service Center,Raleigh,NC 274 19-1636
13a.Yield igpml al9ctlmd of test:
24c.For Watcr Supply&injmtitln Wel4i
^^ r
Also submit one caps, of this farm within 30 days of completion of
13b.DislnfiYtina hpe:-_ - _ _ _ _ ._ Amount: wctl consiniction to the county health dcpartmont of the ccnrntp whcre
_.-
consfntctttl.
Foram GW-t North Camiiru Depatimma of Eaviroaroe n and NamrA Resourcxs-Divi;ion of Water Itesauxz Revised August 2atl3