GW1-2021-03204_Well Construction - GW1_20210625

WELL CONSTRUC'1'�ON RECORD
• y F�ittcrtat)Use ONLY:
ibis fozn,con be owd far 51Mk or M¢14*antis
1.Wdt Cnotrwor_infornlation:
r
a3zo
Stefan Smith room TO I DI 1PI109
NetFCotttroaattfatne ft. ft. 1
3576A R, ft,
NC Well ComrncrorCenircmrouNtimtrr
5,0 l UM SUNG nrirrrrttinmrd1�1WOU ;ORMIX
OM TO L IMMR R f TMCKNTM ]MATERIA1.
SAEDACCO Inc 0 n., 24 ft. 2° ktp. SCE-40 PVC
C*"V. y Naatt 16 T NCOR
PROM TO DGmtIVM I TnICkNIM MAIMAL
2.Wdt COXIM tttion"Permit t n. ft. �►
Lilt ell epplic W WeUpameeftr fir..Cauntn,$W0.Varinrorr.InjeC601 ejr.)'
3.Weli Use(check well Us 37 _ .
Water SoloptF Well, PROS! I TO 1010t "'It I S 17,Ii 11C9CNK-5 IMATMIA1.
DAgiicultunll DMiniMpel/Ptdllic 24 R. 39 ft2° in Old SC8-40 PVC
DGeotlletmal(Heatingtooling Supplyl DResidential Wet"Supply(single) k' I'L
DbldustrrvllConm cfdal DResidential Watt:rS ROt]7
Supply(Sltiit ) FROM TO MATE ESMACEMENTMMOT1&AMOUW
❑hri titmn h, n;
Hon-VA'atersupnly given:
®Monitorin Diteco}
jection ell: tm. �-
DAquifetReclmarge DGmundntlterRcuiediation "14
DA crSt ty ra :H raTRatou, rats tyF:HF�T I:T1 n
(lW =Scanditeco-,v DSttlini Hairier 22 M 39 M Sand 2
DAquifcr Tcst DStotn mcatcr Dmitln6c M R,
Dxptrimcntai Tcchna+tog} OS"ikzrcc Control x DRl1C> C raia itli�iiiai
DGeodieanml(Closed LOOP) DTracet iROM To DRSCR"InO obbr5medn. oWnick qw,trim itt&w
DGeoffierlai(HaliMpoffig Return) DOtber( inunder#21Remarks) 0 M 14' fh Brown silt trace sand
14, ft. 39' li. Brows silt
4.Date VlOO,)Conmpleted: 6/11/2021 Wd.IIDATW-1 'a®
ft. h:
Sa.%Veil Location: (L (L
Teramore Development (L rL pfQf�f:ssi(t�
Facilit}lOwwrNarm Factli ]DR(ifapplxablc)
ft, f1, [ltiru iZ t?
3179 Sparta Rd., N. Wilkesboro, NC, 28659 ft. p,
Ph iml:AddRas Gn:at+d Zip 21' EittAit
Wilkes Temporary well for grab sample. Then abandon.
Co+iatp hatter Idt(diricAtion No,MN)
Sit.t atitade and t ongttodein degreestminatalmcondsor decimal degrees. 22.Cbfifrsation•
tiroult(ietd,one:talrio"a is sidnektd)
36.235935 N 81.1783034 W 6/16/2021
Sibmt ofC .. tedWetlCaauncror Dais
6.Is(are)'(be wdl(s): UPetmanem or OTemporary
1�y sigotivig thin fcrm.,l lkirby trrwA than iltr xetl(s)into(wt<ary[vmrrhircted in ertiandantr
whA.1 bt.NGAC O2C.0/K or 1 SA NCAtC 02C,t1200 M11 Cwtstroalm Standards tend Ora a
7.Is this a repair to an c mAng well: Dyes or 0No ivff of thir nvoaf im been n pm,ldr4 w d r'►sW.l ouncr.
lftrrfris R repah%fill rat k004ya well eo[rat ios iftfumurrionand explain die ntrrrre afthr
reps ram2rr#71,cmarb xmih o or ray dm brwl of thh form. 23.Site diagram or additional well details:
You;may use the boa of this page to ro%ide:additional well site details or well
8.Number of leeks constructed: 1 co nstnlct)on detais. You may also attach additional pageslf necessary.
Fof nwltlrdr Injecrian tv m-iswwr.fM*kWh ONIX%1M the srtatt so>rstrirrdlas.vatr ca»
submR one fames. SUBUMAL fnST UCTTONS
4.Total vdt depth below land surface: 39 (R.) 24a.,Par All Wells; Submit this fe'nn %vitbin 30 days of compWon of nvil
For stutitpJe wefts list 01)*pAr f/do'rec ur(exawfr,-30300,OW 20111V) cminiction to the fpllott ng:
10.Static water level below top of Castag: 26 (B;) Division of Water Re.sources,106nnation Protes+ing Unit,
TJnwter hovel it shove:eddn't.am°+" 1617 Mtn Set-vice Cmter4_Ral*i b,NC 276"-l617
11..Borehole diameter.S S.25° (in,) 24b;Egr Lp ,lon Welts ONLY: In'addition to sending the fort to ft. addnss in
24aabiwe.also submit a copy of this fart within 30 days of completion of well
IL Well vwastt'nCt1011 method.HSA Consu tan to at following:
(i.e.su8er.tutsty.cable dhd posit etc:)
Division of Water Resmlrem Utider000nd Injection Control Program,
1436 Mail Stem toe Center, t NC 27649 1636
FOR WATERSi1PPLY1'l'ELLSONLY: II Raleigh.
13a YietA(gpm) Method oftesk 24c.For Water Sopplf&tnlectimr♦i'etts.
Also submit one copy of this form%iithin.s(i;days of completion of
13b.Disinfection tsTe._ Amount• vvell c cleat. t I �mm mt of the c�mty'whrac
. Smell constntction to the county beahh d,
Farm G\v-t Mott Carolina Dq mmnmtof Em fmnma t stet 1+$iund Resomoes-D'hisbn orUla crRrodums Raked AiCtO2011