GW1-2021-03985_Well Construction - GW1_20210721

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WELL CONSTRUC71ON RECORD �S Fwltsermt t)scONLY.
This team can In ascd for sftle or tnul iplc nails
1.Welt"Contrrtctor information: \
'A it 20 ttS,
Brian Baling r, FROM TO p IPAV
K'ellCeatrncwNam ++ ft. ft. `
4240-B
NC'WdJCoauworCcriIicMio%Nnmher . 13.OtTfER. eft o : (tlt lalY£.R.M bk
Lay�1�(�(}►1i� FROM 170 tIAMFTF.R MTKI TM I MATERIAL
SAEDACCO Inc CGS 0 It. 18 it 2° 3i3. SCH-40 PVC
Cnm�sn Naarr p y t..r � 6�1 A7G�R-. 1NG° `i(clo�da' -
FROM SWIRTER. Ti IC1NT M _FMATERIAL
2.Well Construction Permit tt: ft, I'L
Listefirtppdir W0'VM1 permits(Le.Carmra,Sta^p,Yaria�e.It aetitrf )'
ry. (L hL
3.Wc11 Uso(s w*well Eke):
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Water Supply Well: FROM I_IANMYRR ' A1TSIM, I TInC10,4M 14MATMIA14
IaASItGilltttr8l I Mtttlicipalll'ttblic 18 M 33 (L 2° In. 010 SCH 40 PVC
MeoMernml(IieatitgtCooling Supply) OResieatial Water Suppiy(smite) % fL 11L
C tndustrialfCommcxeial OResidential Water Sttppb-(spared) `k€l3R0 :s-
;FROM TO MATERIAL &tPIAC.ME%T WITI0D&AM V0
13hrigntion 0 fi. 14 fL PORTLAND POURED
Nort-Water Supply Well;
fL ft.
Mmol torin QR Olt
Injection Well: fL
CAgtdferRechargc Cl:iroUTWVM.few Remedielian T9 A" lctinte -
FROM "MA1. , F1MpIA , iGrrML�rNnn
DAtittiferStomgc and Recovery CSaliniic harrier 16 Yt. 33 ft. FILTER' SAND # 2
CAeuifcr Test Ceatatnmater DrtlTntt};e
ft. A.
❑E,VedIncntat Tmbnotoy ❑Subsidence Control
20;1)R11�WNtti7A titicM'ai8dt s tbetis9ti*ccesra`
DGeothemml(Closet Loop) OTracer rRO4M 1 To nxscarprto,a►Ier r, vh «a,vcn s&o ttGl
OGWItlennal(IleAti G1 . Remm) 00tkt(64ftnwider#21Remarks) 0 h. 5' tl. BILL SILTY SAND
5' ft. 10' A. SILTY SAND
4.'Date Well(s)CoMpid d: 6-25-21 WdIIDAM1f-02 10, n, 33, (L SILTY SAND CLAY MOIST TO WET
St.WcU Littottton;
Pilot Travel Center ry; fL
FaA14A)nucrNamc FacHk IDO61'pptimble) m I.
1006_Charlotte Hwy., Troutman, NC, 28166
Pksirst AditiL Cit„and Zq) •27 ItBbt
Iredell BBNTONITE SEAL 14 TO 161,
Coaaly Pama IdetoiAW1104 No,(PIN)
5b.lAtitnde'and i tingiradc in degr ecstmimutcs/seconds or decimal degrees: 22.Certification:
(if nett IleK orr 1100"s issrdtiticto)
W Bria.nu E. n
6/30/2021
Sip=M of0XIMCd Weil Coimactot Date
6.is(are)the aell(s): M- Peil manent or t]Tetnporata gI rfgrtdrg thit form i he m+y re'*thw for#**4•I rm(wry)a mvrnrcmd in a vorAmir
%CAA I3A NCAC.02C.01M or.ISA NCAC 02C ROP 1►'eU Canoft pn 3rur+dards end that a
7.It this arsepairtoancd.*"well: OVCS or MNn rapeaftAitrerarrJkrtsbr�tl�rmhkdrark airidtmner.
(jthts is o repMtfnt Eau 4*m-m well coarnk Jlm kq'amwtW and eviahtthi narpre of the
nepzir wder#3P r arch,verAm or an die hwk of M&jVr= 23.Site diagram or aQd d nal a'dl detalls:
You may use the bock of this page to provide addifiomi' n'site details or well
8.Nuatl r of r+'ells cotrsttttetcd: 1 coustmetion details. You ota►'also Mach additional pages if uacessiuy.
Far»tudrFple trr}ertlan er nm-uwef sWpJv wrW ONLY n ttA�hc srtxteeonsp�ctfoar.votr raft FIlBMCfTAL IAS iYIC t70NS
saGnw qm fort
9.Total well depth betdlc land surface: 33 (R.) 24a. For All Wells: Submit this fanu mithin 30 dn}s of oompletion or well
Far, td$eivrUslisrallittP*#'dt,$eretn con.Str%Coontoftfoflmcing:
10.Static:water le%T1 below top of casing (D,) Division at Water Resources,Information Protesting Unh,
11'4u t h-WI Istabmv 161.7 1Na1f Senlee C6nter,13stldRh.NC 27699-1617
t 1.Borehole diameter:8.25° (la) 24b.Far iokc:tfan Wells ONLY: In addifion to sehding the form to the address in
24a abmt_also submit-a copy of This form'within 30 days of completion of well
12.%Idl COtlslnnflDn tootbod BORED construction to thefotlowhW
(Le.aafr tntaq•,cable.fta unit tic.)
Bt hlon of Water Ressourem Underground Injectl(tn Control Program.
ROIL:WATER SUPPLY 1tr1:L[S ONLY: 1636 Mail Senice Ct?mtr:Raleigh,NC 27699.1636
138,Yteid(gpm) Method of test 21c-For Water See&&1n{otxhm'Welts:
Also submit one CI°of this form Within-j0 daps of completion of
13h.'Disinfemon ove: Amount: cu 11 co str ly health fitment of the counly where
�ve11 constnlc6an to the coon hea department
Farm t'W-t Nanh Camhna Dgmtmmt of Ewfmn ocnt and Mnazl Rcs omocs-0.1 isibn of'lrater RE WuM ttc►,iscd August 2013