GW1-2021-03104_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD For lr*nW Use ONLY:
710 form can be Omit for sink ar MA"nstis
1.Vi"dt Contractor Information:
Brian Ewing RR tii T p> rPfiltti
Well CorA a tvNamt tt El
4240-B
3.001 IiR t:A�lAlti tllr. J *" ffCA
NCC cllCantraCfDtC€fli(lCaliagtiltii$cr FROM TO PTA9t�TBR � AtA7EB1Ab
SAEDACCO Inc 0 fL 35 tL 1° In. SCE-40 PVC
FROM C TOE R DIA ltETB Ltiistil� "
r3'tone FROMTntt'KNESR IIAIMRIAL
2.Well Constructign Pcrrri#t IkL
Ilao teMtlmMe url(por rfls(i_r.Cmrntr,Stair,Varfamre,lfft Oat erg)
3 ♦d)Dsc(check well U.SO:
Rater Supply Well: Oa„ to DinrsxsRI 1,4AWSIV. . rilic Ess MATPSRrnr.,_,.
OApkalruM l�latllniciptfLtl'blic 35 ft. 40 ti, 1° in 010 SCH-40 PVC
(30cothel(EleatingACool ng Suety) Olkesidential Water IL ft
rtm �
OUTdiaStrial/Contmerriai ORt:sidential tooter Supply(sbatod) All tiRt)trP
FROM TO '61ATRRIAL FMPEACCF7F44MarET1iOD A AA ORMr'
❑trr Ilan n. rr.
Nan-VaterSupply Well:
A. (L
�Tr4on°rtorin Cittcco�e '
In ectiou Well: (L (L
OAduifer 114C irge OGrottr dtrntcr R mal utios ts. i,
DAar)uifer S1=ge av4 Rrxovey 13S.-dinity Blinitt aMAPER wnrt a .iF+rrasr r n
33 M40 h FILTER SAND It 2
OAq utter Teg 13Stor mwcrV nage
OexpcAmcntal Technology OStdlsidoxc f'anttol
+O.bR.iG#,1�t3r1p bltacM�ddlttonir4 kCef�"Ins ,
OGeottletmal(Closed Loop) 13TVaeer ;FRo'q To I DES
Pi c»oar n�r�, s��ncir r
Meothermai rCAa4qjg Return) 00iber( `nunder#21 Remarks) 0 it. 201 11. FILL SILTY SAND
20' ft. 40- ft. WET SILTY SAND
4.Date Well(s)Compieted: 6-2-21 Weil IDJI TKW-2 (L (l.
Sa.Well Loeathm: rr. ry,
Willis Grocery/Crossroads Pet Supplies t4 IL
FacU rYhn wr Nmw FaCAW VNF(ir gPPl abl0 M B.
4025 West NC Hwy 10, Newton, NC, 28658 D, M
PlMr i lAddmss:cith,andZip ar 61LA tit
Catawba BENTONITE SEAL 31 TO 33- Ifl OM. ` 5e dO"
f avuw namtt Ideomca llon No(PiN)
Sh.latfit do and Longitaric in degmcs1mJP1txtcstxc6n.d1sqr decimal ftrecs 2L Certifications
(it aott bold,n+K 1*10 is sldtttknl)
lT w Brim EW�"I 6/9/2021
sigaytap orcettiticd Wes Co lMslor Bate
6.Is(arc)tlje weil(s)*OPrtmanent at OTemporrary ors+ s ttrir f@,m,t hereb t�} rn�p thd.rhr nYlf(vl�tx(vt+rr!rsirnttnretrrt:n racot�dmux
ririh l3A NCAG t?at'A1tAa m J3A NC,lt':03C,t1�tt`tQ C�oirsrrtavkxr Shrnrtards antlt?lasa
7.Uthiia repair to,afttAiingwell: 13Y4* tur r8?Ni► eciprrRjthireretsrrl#trs P�+�tJmdJAc�rFJtriur°r,
t f this Ira rr�rdr.fd r�r Pxtflirw well ebaasrntctian f�fur�tdan arrd r�'ttJn,r,6e�lanare��,
rryavirrurmtrr6?i rnmrrrkx arhetirrn ar cc7 d,t buel ai thlx fnrni 23.Site diagrl mvr additional well detaft:
You May use the back of etas page to IftAide additional tsell site de-Wig or'%vell
8.NumberetweliseonstrtitcW: 1 constnletiondeWk You may also altadhadditfonal pages ifimeasary,
forfifumpJe bfjMkmi Of rarxh.aimr Am*W ils ONLY bith die a�rme rnttsdwcfta9,x�ar a�n
setmut mW fi rm SUAMITPAL:jm'I'ut"17©111�C_
9.Totalwell depth below land sorfacC 40 { ) 24a lbr All Wt11s: St►btiit this forin i&itbin Sit dove of completion of noil
ForNafdpleuedsflsrall&TAr1fdiJ}rtrem(er ile-3§,?3WOW20105r) construction toftfollovsing:
I0.Stafilc tenter level below tap ofrasitrg: (ft,) I1i1 islon of Water Rt sof rots,Information Pnbuting Unit,
tjn'rri r tzar!is oetJrrs a raatma.rear"+" 1617 Man Semite C&tcr,Raleigh,NG 276"4617
11.Borehole diameter:2.25° (in,) 24b.For iottxi E Wob ONLY. hl addition to sending the farm to ft address in
24aabothe, also submit u cap of this form within z©dayx of completion of rseil
IL V1rdl Wngrpedon method:DRIVEN owlgtuction'to the fbllowing:
(i&anger.rudl ,wblc;d TW pub cm.) <
Dhision of Water ma.Uedergrifund Injection Contr6l Program.
FOR WATER SIJPPLYWELIS ONLY' 1636 Mast St ice Ccfiter,Raleigh,NC 57699-1636
13a.Yield(gpm) 1 lcthud of test: 24e,For Water S oft&INOWO"♦Ve11s:
.Also submit o'ne copy of this font Mthin:lb days of completion of
13h:Disinitctiitn tv Amount well conAmcdon to the count) he lth depshmctn of the county wheac
constmcred. I
Farm ester-t Monk Camlim t}q%fftmr d of Evvimn an4 Na1unJ Resaumes-Dh loon of Water R@ teen reed ALVA 2813
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