GW1-2021-03308_Well Construction - GW1_20210603

MLL CONSTRUCTION RECORD
1'otirtemnl flee t1Ni.Y:
This form eon be owd far sftk or mu]fi c wds
1.WeRtbrametor.lafomalton:
Stefan Smith rR M DRSPRIPflIIY -
N1'etl Cor4iaam damn A. � j
3576A ft.
NC'WollCanuaaorCortificatonNnntcr 3i 0 fiTAt of a�stdw+e :QR taNTR ti fitcrtik
FROM TO PIAD{M_R TMCKIWMMA7ENtA1,
SASDACCO Inc 0 fL 7 fL 2- tie. SCE-40 PVC
CbflV' ;Nam16.:t Nti Olt - !NG Alt da
FROM I TO DVkMFTER TRWK.NTSA MAIF.RIAL
2.W edt Constmetion Pernift a`:
Gakl0arpPHrUN't MPH Perm"(e_r:Cmrntp:Sh Variknre.Iffecdatah)'
n. n. im
3.Well Use(checluw0l use},a;a
Water Supply Wdt: Rn M TO 'J WA tK"tia ►An 17,}' Iniic�c�ss^ inATMiA
C7Agrirarlttltal f1M111►LelpallPllbliC 7 R. 22 fL 2" ta'. 010 SCH-40 PVC Pre-Pick
OGeothetn al(iieatingACooling Supply) CRes dential Water Suppij•(SjjnStc) ft. io
gindusttial/Comnem al 011csidentiai Wow Supply(ftr d)
FROM TO AIATFMAL ,EVFACEMiVTb=OD@AM0UVr.
Olir►' lion 0 It. 3 1L Portland Pour
Non-Water Supply Well:
ft. (L
®Mgmitonn gtteco�
Injett(oa well: R. rL
DAgnifcrtiechatp 00roundvrata Itcrnodiation fir£
;.
'FROM AYF.RO rMPjA , Ct Mr7 t
0Ag0er$tomge find ltccatvq Mail"Barrier 5 A. 22 ft, Sand 2
❑qui(O Test AStAmmn cr l)rRi 9c
Oi__+cdMcntsi TCchnoiag}. C)SAsidence Control
2tll1R11�.tA G riticli�tlilrlloiiil�lxbis'~tf+kht�wi �'`., ;,
DiGeothermai(CloseiLoop) oTtacer .PROM TO VPS"FVn0'N csbr*.rta 0f0a1rack o , f►
OGeodwnuol(Heatfr ooli Return) 00tder in under#21Rensatts 0 tt. 7 t4 Clayey silt
7 ft. 22 ft. Cemented silts
4,UateWell(s)Completed: 5/4/2021 '-,VdIID#xT-ll fL
$8.WCO I.OrAtibn: (L
Durham Army Reserve Center h. (4 ,1y ' {lit
F= ityA)%v is Nn= Ralik,iDdl of sppItabte) ft. is
1228 Carroll St., Durham, NC, 27707
1111 sVkd A.d(pns.City.and Zip MAMA
to
Durham 2 foot bentonite seal from
cavah- PAamd aderdreatlonw0.(PiN)
5h.1 #undo and l,.ringitrulc in der�c�lnt tRrtsslscrn .
nds or dceiml degrees: 22,Certification:
(if V en lirtti.°ooc Wong is StAkkltl)
35.987716 78.917364 W A5aAmf -21—w-va- 5/14/2021
Si�st Cannactor
6.Is(Arc)tbertdl(s): ZFmnanem or Meinporar) ly rlg vng Ab form.l Aeridry err*,.rhAr Ow u rtt(r)wdr{wrir)t*avvaed Lr&twafttr
,WA 154 NCAC 02C MOO or I M NCAC RIC.OZA91t 011 CorDirer 1vn Smarr*and rhut a
7.h this A repair to an Viistfng well Meg or V No €oRrofrhkr word he brm PMVhW mow nrll anarrr.
If Ali 4 ct irPor.flu out#WAM UW1 ecowr+mtoo 4#~W awt fw'wrt ff a rurrure 4 the
nyairkndrr#?I.rlrtlkrl:Ysr+rlsaranonthrhart dNrfarm. 23.Site dlag sdn-or additional well details:
Your may use the back of this pege,ta provide additional well site ddaitsor ncil
t3.it"nrnberof~wells oonstrttcted: 1 consltnetfon dt tafls. YOU utay also OOCb additional pages if tmcessaryt
For i Jntrinfcrribrrornon-#WersV*W11rONIXRdrAdMamnrcunsaw4m."WHenr
sabenl Me forth. Sf 1RMI7TAI INS'1•IIG"13M
9.Total welt depth below land sutf'are 22 (fk) 24a. Par All Wells: Subunit this fapn t�tii]r n 3O dg4,s of cofMkdon of hall
For WOpie itvlls l7tr oil Jgdu iNiffenvo ler[t+ it-302W&W 3@1(K1') con5tniction to the:twonlns:
10.Statie water Intl below top of casinm (ft.) Division of Water Rtsounccs,informitioo Processing Unit.
I/WOOF Wi l is d6004-edJA A:AW"+" 1617 MaR Service CCn cr,RateW NC 27609-1617
i I.Sorebole diamcbrr:8" (itr) 24b..Fbr 111k0fla We7Is'ONi Y:[Trl addition to sending the form to the address in
24aabore, also submit a copy of this farm within 36 Os of completion of'well
I L Well4MMIrnction Method:HSA construction to the tbllmitlg..
(Lt. anal)•,able. pmdt etc:)
Ah'Cvlon of WaterRe:lant c s.'Viidergtionnd IoJcctlott Control Dirugrain,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Se ite C der.Ralft,NC 216993636
13a.Veld(Wm) Mabod of test; 24c.For Water$agi ft&'tnloc#fms Wads:
Also submit one cM of this form}rithin:30 da)•s of completion of
13b.;Disinfection,type: Amount: nell construction to ft count) tnsith depadroc rt of the county nhm
constructed.
f
Firm GtV-t NDYM Cmotiw Dcpwtmnu of Emimrmxm and M utat Resomers-0hisinn ofAlakr ReWtes Rcvbvl AtCU12013