GW1-2021-03114_Well Construction - GW1_20210625

WELL,CQMTRUC ION RECORD F�intettmlt)xct)NI.IT:
nh foim can be and for single or mtdti*wells
1.Well Coutrnetor:information:
,ik.�ali"8R Z0
Brian EwingrR M orse'lu r7rt}x
AVOI'Cor t'ttoor Nam ft. ft. �
4240-B fL
NC Well CommcterCettiflcationNumber � � of inilti td �cih
FROM TO DLiD TrnCt.'NE" MAiE;RRML
SAEDACCO Inc 0 (L 20 ft. 1° lie, SCE-40 PVC
Com"yName t6,I Nt",:AR'VB1NGti' �.
FROM I TO 6tA tVM I TrnCI+10ES4 I" MATERIAL
2.Well Construction Permit#: fl, 0. h►
Liu ali applir 61r»pt1 permits(ie.Coumv,SWW,Varionre,Tr aka Or-)
ft. fl. in.
3.Well,Use(elcckwdlus€):
WaterSuppta Well: FROM To I VIANKTER 4 S1,oT tU: I TrnCrc M, MAM1614 f
OAgTkultoml t7MtmicipoallPabiic 20 f. 25 (L 1 in, .010 SCH-40 PVC
Moothetmai(Iieatio&Cooling Supply) Olkesidentiai Water Sllppf}"(single) R. in
Oln ntrialrcot Imuciai Olkestdential Water Supply(ftmd) FROM- t--
FROM- TO -:MATSR[Al. B.ltPIACg.M1iri9'afBnrODfiAMOUn'
❑hri' lion It. fL
Non-Water Supply Well:
mmcnitori 17}ttxw� fl. tl,
Injection Veil:
f3Aquf(er'Rcehurge (30roundwater Re noditm �• ' of _
PR M I11ATRRtAG p,tpi,A. r1T _r?fr! n
DAc[pifcr$tOrNgcandl1=vvvy L)$alinityBarricr 18 ft. 25 fl.. FILTER SAND # 2
0AquilerTO O$tclrnmatcr Vns rwvz ti fi:
OExprdmcntalTochnotagf asubsideartcCorfmt
2t1u RU:IAt�' 'I.Otr.ahie6'hi#rlifiotiil hei3df "
17Geothermal(Closed Loop) OTtacer PROM I To nxsMvno a�»» atrwn a a�+msa a erG
OGeotherntal(Hear olil Remm) OOtilet(explain under#2 l Rematl:s) 0 (L 20, fl. FILL SILTY SAND �.•
20' ft, 40, ft, NET SILTY SAND
4.DateWe1l(0Complcled: 6-4-21 WCIilD#TMN-10
tt. tL
Sm.Well ad)t:titlelit: (L
Willis Grocery/Crossroads Pet Supplies fl; h, rC .
Fwflk-10wn:rNnw FacilnW I)N Orapplicable)
4025 Nest NC Hwy 10, Newton, NC, 28658
Piotieal Addmm 01h,avd Zip
Catawba BENTONITE SEAL 16 TO 18*
(kt:ftgi> Pamdlder4lftettlloei No,(M)
Sh;i atitadc and 1xmg1tudein ftmesdmimrtc0sce6nds or decimal degrees: 22.Ciertifmotion:
(itwell rOK otte 1,'d11011S is stdticlerd)
11` W .Bran,,. wing,- 6/9/2021
Sig mum OfGenilicd Wctl Cattttactar Daic
6.Is(ore)the wtvil(s): OPennanent or OTemporary ,is+ �thdt,few9th i LFimin ersn%v rhat the n rli{ai twat(weir)tietitrrtrtted i t cr
u�dt lf+t NCAC 4?Z';a/(MJ or JSA i'VCAC R1G,OZO?11't1!C,arstrtutihat SAnndortls cad rti�t a
7.Is this a repair to an a dsting well: OVes or MNo 'ropy t f l*kr r turf hax brew pnn-444 to xtril awarr.
if this ix to rePOr.flit our kWWV3%TU c»urtnWitort m*MWrJon snit r.XVIOlt 440 mantra of rht
,rWir ern4rr021 mmanks xretisin or tm At bark of this form. 23.Site diagram or additional well detalle:
You may rase the lack of this page to'pmcide additional w41 site details oruill
S.Number of wells constructed: 1 conmuion details. You play also attach additional pages if occessary.
For nMOtWe tnjea;o rorwm-ismer jW41.r writs ONLY ndrll.rhr wmtmnspwcOon.vau eon
s'+bmamirfarrm SURNILML INSTIIC'FIM
9.Totalssdl depth betoir land surface: 40 (n) 24a. Obr A11 1VC11k "Submit this form within 30 day%,of complttlon of W1
For millripit+sYtls'GsrnJJ rirp±tJrr ifdi�trrrrr lernrryrN 3 '?iMi"Dial?�JAiP) amstnmtionto the fotkming
10.Static water IMI below top of erasing: (ft.) Dhislita of Water Resountee.Ioforniation Processing Unit,
r/karma we»s dbove edtkg use +� 1617 mail Service Center.Raldo.NC 27699-16I7
11.Iloneholc diameter:2.25 tin,) 24b,Fbr Fnfeetion We-13VNLY. in addition to sending the foam to the address in
gas abin e. also submit a copy of this farm within 30 dais of completion of►vil
12.Well rnnstrnethw method:DRIVEN amsttuction to the 110110Wing. �
(i.e.stager„rotary,cmble,died push etc:)
Division of Water itesoat+ces;Uedet-0onnd Injection Control Program,
FOR WATER SUPPLYTLLS ONLY: 1636 Mail Senice Cantata RaleO.NC 276"-1636
13a VfM(gpm) Method of test: tic.for Water SupAX&l oWton lVdis:
Also submit one copy of this form afithin'zU daysofcompletionof
Obi Disinfection hlic: Amount: u-e11 conswiction to the cDlmty 16hit deµ oment of the eounh whm
constmctod.
Forn1 ti134! Noith Camlim Dq a um-v1 of Ea%4mnnxni and P mzW Resowms-D)<fsion oMater I m: r rm Rc%iW Aa 2013