GW1-2021-03109_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD Forimnol the ONLY:
'this form clip be omd far 51m&or muIrwk wells
1,*dtContractor Intormatton:
Brian Swing R M P IM03
tvettConknctarNam ft. ft.
4240-B R'
NC Wed ComamrCcnifkmionNnmbcr IS,OUTER STNf3 r ft"eIt 'OR:' rNs scab
FROM 70 DIAMETER . TH10mm MATERIAL
SAEDACCO Inc 0 fL 20 (1: 1" ' In. SCH-40 PVC
t6. N =f)Rs- INC- .. t�irztitlauda
ComPmq'NamFROM I TO DIA.lti.TER TnK'I.NM T MAW.RIAL
2.Welt Construction Permit#: ft• to
List 40 appUrnme wrttprrmio(i P.Cauny:soar,variomrr,lr*dm rsr.) �- n,
in.
3.Wdt Use febedc well n,): 3
Water Suppty Well: FROM To -otAm mR MAIM At'
0Agl cultural 20 ft. 25 fL 1° 1 .010 SCH-40 PVC
ccvothenlatt{lleatinglGooiing Supply) m sidential wstersmply{siDght) ft. to
01odustrialtC,ommercial ©Residential Waters stnm�d) it GRo
( FROM, I TO MAT9KAL Q"LACT24C%TMVM0DRAMOUNT
Otrri tion ft. fL
Norl Watcr Supply Well: ft. ft.
�Manitori f]ttecati
Injection well: n. ft.
ClAgteticr Reclrrge ❑Clio-rndt+tttcr l2elttediietialr 7
13 . refer Storage and Rtmoti' OSalinh-Barrier va rn I r. FMrr A
�$ �� 18 R. 25 ft.. FILTER SAND # 2
13Aquifer Tc9 0StonnwWcr Diainagc
ft fG
Dexpr6menkrl Tee:lmotogy ❑Stftdcmc Control
��1tI1�4,dM1f3d0�f3tatisci��itli#N3+rn,sbtcNsif�aressr
❑G•odomal(Closest.Loop) OTtaoer vROM Tu aFsctttmov osror enrta Yn�rsrcer n s etc►
oGeothennal fi oli Return) 00the r wider#21 Remat&s 0 fL 20, fL FILL SILTY SAND
20- ft. 40' ft, NET SILTY SAND
4.Date Well(9)Completed: 6-3-21, WdiID#TMN-8 (I, fL
S%.%Vcd lmcation: 1L ft
Willis Grocery/Crossroads Pet Supplies m fL
F�Oei}°/Orti'o:rNa+tR Facility tDRfi€appljcdbiol
ut It
4025 West NC Hwy 10, Newton, NC, 28658 R
P1gsim1 Addmm C.itg_andZip 21.:Rf h
Catawba BENTONITE SEAL 16 TO 18!
eftnb, }'arCCt ltlCtdittelri(+e Tio,(PtA}
Sh.Latitude and l m&odc in degrmsfifibmtedsce6ndsordecimaldegrem. 22.Certifwstian:
Orwell r*K mm boons is sldlteictn)
6/9
N W -Sri'--n,Ew i, ,g..„„ ,2 021
6.b(are)the well(8): t3ftnnanent or MTemporar'y Br..itg dns skit fosse !krretry aYrtifj diet tiu n rli(ri r(wr.e!twasrnrrsed in atoordrmee
,riah-Sit NCAC 02C;ti1W or IS4 7+FCk 02C AM-Well Comriymimt Srrr *mAa end teas e
7.Lc thh a repair to an odsting well: Mes or MNn rgsr pfdrlx mrnrrt Mai tKrn n,mtdrd rn iM1r ravttr�w9trr.
tf Als ix o repaalt flit rmr p m UT11 eorurmvion infornm4on"d exptaln the name Of the
repuirwtdrrB?1 re marks wet is cram the bark of this form 23.Site dia2mm or addltlonal well detalW
You may,use tbe'back of this page,to p;;4de additional well site details or well
S.Number of wells congntctrd: 1 e m metioa deta ts: You trimy also ittme b additional pages if twasor..
Farmaftinit trt/e+crlan or arra•�virer ss�#dr+s�rfls OA'l.Y n�tl1-rJu msne eosrspvrctian,von�» C iRA9ITCA C'PI TgS
rahaur a c fares �` j.1�-�' mas.
9.Total wdt dgnb below land surface: 40 (fk) 24a..For All Wills: Sabmit this.form within 30 d*,s of eompkdion of well
Fornraltipio Mrtl#hiroll4oprft(fdifferem terem dr 302(1 'oW 261(kX) constnlckn to the folloning:
ln.Statit hater level below top of eminw. {R.) Dit islon of Water Rt sdurt:es.tothnnstion procasing Unit.
if w0wo,Mt 1 it above cvr 0g.we"4" 1617 Mail Ser iec 0,entcr.RA160,NC 276"460
11,Botrhole diatnctt :2.25 24b,For tnitx.tinn®Halts ONLY:1:In addition to sending the form to the address in
24a above. also sv91mit a-:opy of s this ibmi within 30 da)'s of completion of tail
I L Weil Conslraetlnn 010hod:DRIVEN conrstntction to the following:
(Le.auk muty,t9bit din d push ew.)
Dlt'Lslon of WaterR..mums Underground Injection Contrdl Program,
FOR WATER SUPPLY IVEt,L5 ONLY: 1636 Mail ServiceCenter.Ralelgb.NC 2 6"4636
t3a Yield(gpta) Method oft 21e.For Water Svpplj llc Inj¢Won Wells
Also submit one cope of then farm Imitifid 30 days of conVetion of
131).Dhinfec ou type: Amount: well construction to the county•I&ih deptuhnent of the:cot"w•h=
Form G%V-t Noah Camtina MpmUnmi of Eadmmmm and A nmW Resonrocs-Dn skn of Water R esoa es Rcvtscd Arrgust20t3