GW1-2021-03115_Well Construction - GW1_20210625

WELL CONSTRUMON RECORD For tnitenml Use ONLY;
'tt is k m can be and for single or multipk ntiis
1.V6 Contractor.lnformation:
Brian Ewing NRO'M D tMON,
wdl Cortraewt Name Q. R. I
4240-B
ti OpTlydt Crttur.:' Ntraisevl bNt#iil'1PR f" iletlb _'
NC wc)t Comr�dot.Carlit& l na Afnrl>! r FROM To rMAMFTMER T"WKNFM MMERIAL
SAEDACCO Inc 0 h. 20 tt SCE-40 PVC
Cot*ww Nam
iti,2 GSiI+TCAR1
Mold TO DiAMETM TMCARCM MATMAL
at
2.Wdl CnnAmcdon permit#:
liffi alhwfirwr xTupemdo 0 r.G'aunN.Scotia;Vnrinmr,Irf 66n etr.)
tl, ff. in.
3.Well-Use(chock well asc): 1. tt!CN
Water Supply Well: iN
.To nrAM TnR stAT u0t: -nn13Agricuitual alvimicipallftlir 25 f% 1 rb .olo SCH-40 PVC
Meotivmal(Heatingtooling Supply) Oltesidential Water Supply(single) fl
®bldustral/Comroerciai OResidential Water Supply(shared) FROM I TO r rinreatat RMtw t ateriiOn ac aMouxT
olmontion ft. h.
Non-Water SupptyWell:
Mmonitori E3R=o-.vq
tt. tl.
i n ecllon Well: h, (l.
QAqu*rllccharge DGmundwatcrRancdlation
OAgt ter Stngc and Rccavvq OSslin'nry Barrier FROM rATrara ,,rrt A.,, nxr n
18 ft 25 h. FILTER;SAND # 2
DAquiferTiest Ostomm'Btcr6m nage IL ft
Mxperimcnai T Imto{h t]Sicbsidtarer Csrnlrol 2A':;7DRn `(I N UCi ffft<scM'BCdiilttbaa141rc�ei if "
OCkothemml(Closed Loop) O'tn= _moil I m 6"Wrft%type,two W')
OGeOfhettnai atil RetMM) C30ther(e*131n Under#21 Rt0i &) 0 ft- 20' ft. FILL SILTY SAND
20' ft. 25, fC ifET SILTY SAND
4.DateWe1l(s)C6mpicted 6-4-21 RrdIID#TMW-12 h.
Sa.Well:tAkestion: ft ft. - •,dJ
Willis Grocery/Crossroads Pet Supplies it (L. f
Facfl4j0nttcr Nam Facilq m#(if wpikdblc) rl\
4025 West NC Hwy 10, Newton, NC, 28658 ft. ft 1 +0L' 6!1111
Pl\rai d Addmm Cig•.and Zip .3N-�;kE.f B S`.: .. yam_ v
Catawba BENTONITE SEAL 16 TO 18';
(AMW P.tma tdemirkation No:(PIN)
Sh.Lo ituda and tainAradc in dcgrveslminutcslseconds or dsctimal rtegrecs: 22. Q:
O t welt tleld,one b0onS ii sid ktd)
,Br an_FW 6/9/2021
sly orCeniiicd west co,maemr Date
6.Is(are)the rell(s): OPermanent or MTemporary B e INt form.I&rro tvrdly that tlr xeD(i)tray fwereJ matnreted rn ai<rordreiar
ufrh 15A NCAC 02C.01M or I SA IVCAC 02C.0AV hell Commmian Sftr4arrk end-An e
7.L this a repair to an existing well: 01'es or MNI► ptorkk t to she nrll mmer.
ff s*04o repMr.Jill out Apples uvll emm nnWan WarmerW wW expla ar the ateratre of the
retry,"rrnrdrr$?!rpanorkz srreiaxa ar.nn tlu bnrt of rlflx f»rm. 23.Site dta T�'am or additional well detaMt.,
You may Use the back of this page to pro%ide additional yell site details or well
8.Number of wells constructed. 1 cbnstluctlondetails. You my also a tadb additional des ifnecessary.
For—MrJe ht&-Moi of smi-wywrAap#y wrils OA'U"M fir annr mnstrurtkvr.,w eov
s"bmiit one farm. SUB11'II1TAL INSTUCTIONS
9.Totalstcltdepth below lard surface: 25 (tt.) 24a, A)r All Wells: Submit this!'onn nithin 30 dggs of completion of well
Formrrtripk yxfls hir all r ep0ar ltdif'Xrem 10%# Mt 3@200`and 2@1W) Construction to the-;following:
10.Static water Intl below top of casing: (ft.) Dh`fslon of Water Resat iries.Infilrtnation Processing Unit,
1f tinaarr k_M u dbm a edlint MM"4" 1617 Mail Service Cater,Ralcigh,NC 2 56➢9-1617
i `
11.%fehote disructa-2.25 fin,) 24b-For inMO Mlis ONLY: 1n Iadddidon to sending the foml to the address in
24oabove. also submit a copy of this fowl?nithin 0 days of completion of well
12,Well eonStrMlon u%Abod:DRIVEN Constmetion to the following:
(Le.#AWr totarf,txble,duecaaaisk4*.) `(
Dhiision of WaterRewras,Uff4er�r and Injection Control Program.
FOR WATER SUPPLYM9ELL,S ONLY* 1636 Mai!Senice Centir Rstl ,NC 576991636
13a.Ytdd(gpm) Method of teat: 24a For Water S ELIE&in oetion'Weirs:
Also submit one cop3'of this font Acithin 30 dgsof completion of
43b.Disinfection hTe: Amount avetl consinxiian to ttu corm h>hcift i depaitmart of the county where
eonstmcted.
From i%V-t MoAh Carotins Dgmtm-W of£m3mwwM aid t-biutal Rmu=s-ll-hisioa oMater RenrM Raked At�uStiAt3
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