GW1-2021-03106_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD
This form ctigbe nsW for sim*or vdiiptc u fls
1.Well Gintractor nfottnatlon:
Brian Swing PROM im A.PRe K
Well Coiekrmix Nu* 0. ft. !
4240-8
NC 1Vtl€CorrtmetorCcnkCerakiuu htsi rr ' S+4 (3 r fig'. rid ' Qitl s Hcabyi
FROM im 01AAMM Ttr MMMS MAIMAt.
SAEDACCO Inc 0 (L. 34 tL 1° n. SCH-40 PVC
f°"ll m'ttA r t6:1 fl OMR ISIBIN st:x �.
FROM Tp LtAMFTER Tn€CKNM I MA14:RUL
2,NV41 G1n.0metion Finrniit
Ir"uatl apgGtrd�3r urrtt prmrTts t%:r:Counry,Stale,L'ariaroCr,7rfai'prai ra',,•i
n. n,
SVaticr Supply Well: FRO&I To _ n
'M teak Ttttry IN MAT'161,_
DAgticttltuml t�T micipalllrltbliC 34 R. 39 (f 010 SCH-40 PVC
OGeothet alal(lieatingtooling Supply-) DResidentGd beater Supply(single) '
olodusb'iallCoknmercial OResidentisl Water Supply(shamd) iillOtYT srwrgRtwt ei►>gcw ai}'rTeon A AMO tmrr
❑hti lien ft. ft.
Non*'Water Sapply Well:
i monitotin gRecosc tG
Injection well:
I7A Inc,C1Groundt�ktcrAcntCditition =S ' �► t
DAgttiter Stomge and Itecomy UsIfinity Barrier va tw tAi; rnrtrl q. tt°real. n
32 tt. 39 n FILTER SAND # 2
Mq ulfxr Tea 11S ocnni*ar DrnimV R. fL
O):xpedn=tal-rvamtilo y 0S65idenvo t"ontm# Y0:-ARIt tw. WOM1 A r=
13C othemal(Close Loop) OTracer FROM 110 o$SGRt ON w»p Msrla 9 WftXk R MN arc.
oGeotliettmtl OefiMC DoUgRetum) ❑Othefl ufldCtl IRemku s 0 M 20' tt. FILL SILTY SAND
20' ft, 39' ti. WET SILTY SAND
4.11ateWell(s)Complete3 6-2-21 WdIID#TMW-4 n 1L
54.Well UtAtion: (L ft.
�4
Willis Grocery/Crossroads Pet Supplies (L tG JU
Fuc1M1yJ %,n fNmm F ilO?tD✓ttsCapptiatite) Tt. te: 1S
4025 West NC Hwy 10, Newton, NC, 28658 t, n ���� ri sec ton
Pto}siml Addmm City.ncM Zip 2tc t614t >, y R
Catawba BENTONITE SEAL 30 TO 32'
t"do t t�Cl td"mifirttiiion No,tl+1;V)
5N.JA tudc and Ungttude in do elm sates/s onds or decimal degrem 2L CtriCcat n:
(lfh*il fak L one MUM ismd kk0l) Q r +�
W V It„! 1 EW1 n 6/9/2021
,.., k,�.� .,
ftm m otCtatif d Well convadar Dick
6.1&(are)the ell(S): i 3FermanNit or zTemporary 1tr 3'gnhx t imr uams 1 Y rr }' •rhea the,arnp,) lamer]ajmAwted in atcardmre
i4th 13A NCAC fi2C-A/M or 114 NCAC OX;OZM ll'r11 CPmfrts vim Stmttfcr ;wid thate
7.Is this a Trpalr"to an tAs#ngwell: £7YL#i or ktmNo et+Fs of thirrrrarr!lava d�rrw;irmt�drd to floe Welt rmaer,
1/ti►is 1t to re�ttr.,}i!t avtktx+rc�x*e11 rautnrctitm i�am�tiorr seal ra�ylttitt tht�Kan+re rd'rhr
"Pwr wmfert21,rmarfa xedo"or the bark of rAis Joan, 23.She diagmulor additional well detAq:
You alay use the Wei;of ft page to ptoAde additional well site details or well
S.Number of ntelis cutstmeted: 1 consttucliondtaits. You may also atlad►additional pages if tccemyy
Form bil4ehtkakmoram-warerszlppk"h ONLY ndth the mmrtanshvnrtku.uduram
ra�deat3t+xtrlWrra
l loans► r ide pater!bnr land surfacer 39 (n) ,form tii9tMa 3tl hats of aontphxion of rst It
9.Totall well.depth be 24a. 1M1ir Ali Wolls: Sabroil A►is
i t iStAr(i°di e+y ut fexirr Ja 3 POfl gat t 11r1r1 consmiction to the-foltoming.
t(t.Sftdt water level Below top ofeasing: (ti<.) Division of Water Res drces.InformunonPr0ttWng Unit,
If nvaw Wd it dbot'e ev dmg '+ 1617 lklO Service C 6tor,lktalegk NYC 27699-1617
11,Borehole dianrett :2.25° (in,) 24b.Egt1p,WWUa Add ONLY: In'rtddillan to sending the farm to€he addrm in
24a56me. also Mtnit a copy of this fonn4ithin 30 days of completion of tall
12.Well constroctlon(n thed DRIVEN ca4i9 mcu Am to the fouom
(i c,mper..ratuty.tubfr,6-ed pasik tW:) I `
Division of WaterResoorces.bideMvund Injection Gontri lPrognim,
FOR WATER Si PPLY tN'FUS ONLY 1636 Mall Service Center,Raleigh,NC 2 69N 4636
136.vwd($pm) l4lcthod of test Zae £nr lVattx$[loll!!aSc nitxtitkn'�Vdks.
Also submil one copy of ttds form titthin.W dayi of completion of
13b.Disinfection type Amount: Ammil conshuction to The mm y heattti depshmm t of the rtnrnlr iris
comma, i
Fenn G%Nf-€ NmthCamhm D.Vwftmm efEmimmwnfmdM al Res wms-ftisionofNk?aterR ms RoisedALVA2013