GW1-2021-01609_Well Construction - GW1_20210404

` ELL CONSTRUCTION RECORD p�intemalu it:Y:
71b form con be uwd fix sn k ow ndrq* vcd s
t.Well contra orInforittstiow k
Stefan Smith Foom 110 013CRIVIto'I
11141E Ctrrr£4V&Nam gOfL
ft I
3576A ntAMW7XR THR169FIM MAiERIAL
SASDACCO Inc - ft. 2° 1& SCH-40 PVC
Orr Y Nam t! :T13dt 6 DUNIF.TS Tt MATERIAL
2.Weil Grnstr acthr Permit#�; to 1
Irsttst9apFlirtahfrutUparmTlstit Crrunnd,Sttrxr,ltarir+nrrA Ir��Oorirtr._y
3.1,"1',cdit3��ehecl:"tvoliusejt q�
Water itimmy Vdt: ._ ti►A�SfRTF:R rprstx�r Tto: n MATttRtAt.
C7AgItC1)lttl[8l i }ynlljitip6F"J/Pt flit 4' ft. 19, fi, 2 .016 SCE-40 PVC
CGathenrgd(jjet tinOooii%'SWjy) C)Rtsi&-ntial Wgtct bttp#}'(singk) n' is
0110 t niallconmm'dol Ol co*nthit 1"'atersvwty(sha W) #ti lRt)i37'"
trAOM TO 34LArBRIA 1%tPLACi.31if�Si11WMCMIAmouW
Obvigotiall 0 ff. 2' ft. Portland Pour
Nop-Water supply Well:
ft. ff,
dmqudtot n Cll ec01C
ttjettion Wend
(3AgVfRC� 00roilndsaterRcaRedistion
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r, rr.a.� ►�vAria.xtr n
t Af rifci5t0rta$e fltrd Rcc rt} CtSittinit)' arricC 3- 0, 19' ft. SandRrA 2
OAgpf(crTesf OStommnterDmira C
f#. ff:
17F,%pot M=Ml TicchMtW ❑Subsideface CoMMl
"36.D1tt1 `ti•1.4tTfattir�iisddtd `tda ���"
00cothemud(Closed L;oap) t7 ram ,allow 170 aEsratrc tIo c tAHf:9crdn f r y tre l
❑t.,eeodr.MW(Heafi oelit R.etnar? ❑Other( n under#21 Remy# o /t, 7 tr. sand
7' (t, 11' ft Clayey'sand
3.D8t0We11(s){bmpieted 4-4-21 WelIIA#Mw3 11, A. 14, (t; Cemented sandy silt
Ss We"tdrL'Utii)n 141 0 19- ft Sandy silt
Former Circle K h, ff ` \541
FhCrOit/Ou'Mrx8 r Fmilily IV#Caf tgiplicablc# p. fL ° _
3000 Jefferson Davis Hwy, Sanford, NC, 27332 ry, A. `a Gr,'
C
E'10mol Addmss City and Zip 20stiaA
Lee 1 foot bentonite seal from 2 to 3 feet.
Cah, Party iA:fsSfkttuetia.(rtrl
5b.LaOtoO,and Ungttode in dcgive clmi`n3k0 nds or ttC mal ttegrecs: 2L Ctrtjf on:
35.416459 N 79.229522 Fy &_1Wd__'1i-_'uzC_'.'a-i-
3/19/2021
Ave
6.Is(are)thewd1(9): OPermanent or OTempor8ty
4 sigtias tlrit,t+rn*1 hrrrky I*rtlfv IhaU Nx rt,elt¢sl lass fafti+w)cwauzrrted&r&Irorsfkncr
Oh l.SA NCAC 02C.01TA9 or UA NCAC:02C 42M V%off Cmufnet° an Sft adar&widow a
7.Is this a rcpAir fa an e7rC:tt ng Weth OVft or MNo rq--0lrhi1 nVorrllw teem POW&kn tome urn auwr.
Ir irmrrdr�1�rnmar&s re ivil n or m the f�fn .,fi,an ear�t rtlrTat±r t1u+xararrr�fhr 21.Sited nor or*dditio-nal welt;;
tietalts:
# Your*tse die 1 &of ft page to ptaxide.additional 11tlt site details or well
8.i4#ttabCr of�►etls aLastrttctcd: 1 eonstniction details, You may also aflach tt"fibtu d pages if necemtv.
FaPaituta#nkigkwkovrnm-4wersjTp -ve1lsOM1tYw1r7br,smromsfa°se4m.;wa,s�
sohm eom foam. SEMMi'1TAt Ill ?ttf`PIf�I!`S_
9.Toftlwdl deplb be-low land surfam 19 {t1 24s. For Att WOK: SublAt this ifnnn tti11*0 30 OM of COMPlttion of well
Farm9jfip r consnuckn to the follm ng:
1Q:Static 1►ater level belmr tap of c:elnr 7 {n;} Division of Water Resoartes,lnfonnstionPmc+essing Unit.
If ismer kvrl is ON"C6048,AW 14 1611 Mall Scrsice Ccottr,Rutcio.NC 27699-1617
11.Borchate dismetrr:a.25 0 24b.:F-nr tnitrtlon i A'W'ONLY: In addition to sepdiDg'the foftn 40 the address in
24a above.$iso sttbtait a Copy of this fern%thin 30 dws of completion of well
12.NN1dI C4riStilFCtli3lt:rrll`tlrad;HSA cormsuction to the foliouinx
(Lc:mWr rMq.tabk_dinxd pasta CtC
Dhtilon of WaterResoorcrs.IInilergpoond Injection Control Program,
FOR WATER Si1PPLY NNELLS ONLY: 1636 Wit Sef flee Celnter,Rat ft,NC 27699-1636
13s Yield(gptn) iVlctbod of tact: 24C.Ftir Water Scpn#�tYc 1nja9{oa tiiclts;
Alan submit one copy of this form vratbin io da}sofcomjLleflonof
13h.Disinfection tap Amoaat; Anil constniction to the county txfitlh'dc^lmrlmcnt.af ft county whofr
Cttnstnactod> f
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