GW1-2021-02741_Well Construction - GW1_20210512

WEII CONSTRUCTION RECORD For trt nW Use ONLY:
Thn.form con be aced ft single or mull ipc wells
i.�;"dt Genttmxor�tdarnretlon:
,tar`+ •A'1'�
Stefan Smith PR dr D C.1tiptIO r
WOR Corttmdorr tic n. ft.
3576A
NC WeR Coramctoreaniferaiion Number S.011TlrAi if nr^ i ntlyd u�rpa fht ' i Rci6fe
FROM I TD nrA31rPM TnX%NEss MATVHAL
SABDACCO Inc 0 tt., 10' fL 2° lD. SCE-40 PVC
CaugKiny frame I6jNMQ.9WM0R 1NGr ,< ►twr at lop
PROM 7O DIANIFTER I TIBCA'ffM MAWRiAL
2.W dll Oonstitictl0n Permit#: n. ff, irr.
I Wall arp arame,WU jWnwo far.County,swo,Varinwe,Irpecdart fir.)
3.Wdf Use(ehcdcwdl usc):
Water$npph Wdi: OM TO W .01AMATRR sr T'St71r' THICyC;TZS MATERIAL
10' n. 25' M 2" In .010 s PVC
C1Agricllttunil Oldank p 11hiblic
OCroothennal(HeatiniglCooling Supply) DResidential Water SuppV-(Mnge) fL iL in,'
ptndustmllGam[nctciai OResidential Water Supply(suited) Fa3Rt) -
FROH TO AiATERiAL '6MPLACTSATrriTMWROD7AMML
Oirii iron 0 (t. 6' fL Portland Pour
Nor-Water Supply 1ve":
n. n.
mmonitori OReC6ti
Injection Well: , n'
OAgdifcrRccha%e O(;mundtimtetltemeditttion 10. A R
FROM rA RtAt,. tQNt9�1(4711FYTAI)Fn n
C)ArluifcrStomge and Rccovery OSsiinwVarriet 8' tt 25' n. sand 20/30
❑Aquifer Test la'Stommvtcr Draina
fL ft.
OExperinlLRltRITWinotoa OSF"&—,='Com-a1
1dI.DRI1;�,3 t3lA('i`rifnFYtlitioaiff t�Ws.Cnet��s�In
OGeofbennal(Closed t"p) OTi'ac er FROMI 170 DFSCRr WON "A".I IM_ enW K% ena tM.
OGeodienwi(Heati ool Return) 00dw(explain under#21 Retuatt•s) 0 IL 7- fL sand
7' (L 15' (L Clay
4.Date W HO)Completed. 4-6-21 Wdl1D#BM1t1 15, ft. 25' (L Silty'sand to sand
5s.Well Locution: n. n
Trimble Plant Road Property n. n. 1AY 2 2O
Fpc11hylD%=r Name Facilk TDM(f upptimb1c) n, n.
175 Yadkin Rd., Southern Pines, NC, 28387 fit, tL fl Cft�;3�i0 nii
Pliyvk l Addmss C*.;wO Zip 21 RE1t1
Moore 2 foot bentonite seal from 6 to 8 feet.
c4tarh pareeildtm t'kelianNo.(I'lli')
5b.)altitude and.teni;ttude in dicgr ceOnlmtWffC-vonds or decimal demos 21 CerOwadnn:
(U»ett tie&I,apt WOOS ie ttditticm)
35.190760 N 79.379044 W ^.. 4/21/2021
Sigel of red WCI1 Coaitactos Ditc
6.Is(Are)thewell(s): .OPermanent or OTemporary si earn f he rr rhra rbr,rwl yl react wtrrl c�ewnrared h&-rommhe,r
�' 8+�1; I ►+�� Ott H' (
xtrh i Sit NCAC OX,01W or 13A NCAC tr:C R"O WU ComOrW.en&arr or&and Aar a
7.1.E this a repair to in ezlitiag well: OVtt or MNo egi r n�thG morrf7u�brca prznkkvt rothe imc+�r.
If ft b a mprrfr'fall oar kWAM writ mrArMW11"&owwrlon and r�wfafn-rhe Aarlwre of dk-
reMirW&4frRll reararlx.vWiW or an tine bark of tfib form: 23.Site diagram or additional well detalb:
You Wray use the back of thts page.to prmide additional well site details or well
8.Nomberof W ells eonstructed: 1 cmistluctiondetails. You tnay also sc6 aMhotel pagesif necessary.
For a Wj* rcrlmrofavAr-woreriuPF"€a'w1hONLYtsfrhdiewmecpnsf egotr.;uan*+sm C UD _rfA .1111� C17bN$
. 17'I
9.Total well depth below-land stafam 25 (It.) 24a. For All Weil: Submit this fonn vvithin 30 days of completion of"VII
Forma(trip k wells Howl)rlrpsa#t ff4erenr(eve mph- anvi:iWr) Construction to the follouing;
10.Statle water lLnvl below top of casinW. (R,) DivIslon of Wattr Ra6uftM Information Proeft-Ang Unit,
ff h1dWr kn•rt is abOWF M111 C.vex,"+" 1617]Wail Service fir iiw Ra16*NC 27699-1617
It.Borehole diameter 6 51 24b.For IgWan ESM ONI LI In addition to sending the font to the address in
24a above, also submit a copy of this fottn will fin 30 days of completion of well
12.11Td1 a►nstlllc&n method: sonic construction to thetbllotving
(ix.mita.rotaty able,dite a push etc.) DlrlSion of grater Rem ces, UnderVvund Iinjea:Elon Control Program,
FOR WATER SUPPLYMIELLS'OiNLY- 1636 Mail Sen ice tenter.Raleigh,'AiC 276"4636
13a.Vitdd(Apm) Method of test: 24e.For W iter SuggiX&tnjoay 1n WrJls
Also submit one oap3 of this form`leitlnn:30 days ofcompletion of
13b.:Disinfedion type Amount- vmti constriction to the comity Wolih dcpawrtnxin of the comay when:
constructed. I
Form G%%'-t t♦taph Camlln3 D rrtmcnl of£tn imrmrru mrd Nanusl Rcwalxs-Dltstou oL Wafer R Rn-W AApA 2013