GW1-2021-06304_Well Construction - GW1_20210915

WELL CO
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1.Well Coeteacturl(tformallon:
Stefan Smith FROM To _..kWI1ttPlt0
W'di Contra aot Olin
3576A E
NC Whit c'On umt Canlfxatios Nunber tifS� tT1 oi?attf { 1� _
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SAMACCO Ina 0 (L 22 ft, 2" to. SCH-40 PVC
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2.Wdi Construction Permit : lit, it.
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3.Wad 1Jw(clieC1s will tt50, -
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CSf# LthillJM1 13MatSi poU@ablic 22 A 32 ft 1 2" k .010 SCH-40 PVC
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Non-Water Supply Well:Inje �
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!3A!]ttifcr Storage and Rccsvv} [i5atnitYRORicr � ,r ia� vt �r�rrlwt�
20 rt. 32 rr. sand 2
G1 Aquifer Tea Dminop fL tt
DEVzrimeriftl Technology 0SOsideacc Control
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QGwilictmal tRenti r C.00l Rearm) C30tlwr t utdr#21 Rema&Lj 0 ft. 22 IL Silt
4.Pate Well(S)GDMplcleds 8/26/21 TMW-1 22 to 32 ft. PM/ro
WtI1IIIi� -
$0.Wen Location: � It.
Wishner Green 9?4 A. ilia
Pact7iff tQs�QcrTlsut Fasllin'lO i(if app}icalrle) r
rt.. ft. I:vsii.• �'
201 S. 12th St., Bessemer City, NC, 2$016 � �
section
F1c*arl Addms City:and Zip
Gaston Temp well for ground water grab sample.
5b.1,4tcrde sad Longitude in degre sttninutWs ads or decimal deg"= 21 Certific atlun•
(if-Aail Wd.of ku'lons is so tcierd)
35.283964 81.283680 9/2/2021
Slit oft?c. tttd Roll('arraktnwt iYa3r
6.Is(arep the wrell(9): nPetmaneut or 'i10Temporan
!f,'r sti'S,eirt)r atr8x,12Mm,d drerekt ceratifv tirrrJ She isv?l{sd nrry fmrrrvl marrrructect ue srcvvrdunew
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7.Is this ar repair to an existing iPell. E'Vo or MNo a r ar¢rfakis rrcrarrd liar€lire»aar»rided rn aM ard2:r+uatrr,
df ttr%�ex n rflaair.ftr7 mear;�trr�iitw i{;rid saras�sm tiara nnforrRrrrio�maai rs+pl'a►ir tJu�nararr njrke
rc n�ir ttaraer B<J r rrnrtrfias ex ttei�r trr at rhr titsrk rfJ this furor 23..Sift dlBj+,t in or additional Well Retails;
You may use tire,bwk of this page to proMe additional well site details or w4
S.Nutobtrof wrens constructed. 1 tnictiuradetsiFs. You May alsirt if t essitry_
FurnraFrfpfrtosrtW&rrarrn-waternwpkweltvONLYWthdie rrmaeoatarractdmt ycxae�e
subAft one form Sjj2m=41 MSJJ CPfM
9.Total well depth below land surfaces 32 (tt.) VOL Pnr.Aq�lF hg SOmit Ibis furro �r thin 30 d of crsmpletiorr of well
Far aRaciOP(el W(Is NO rftiffer0s ffAftkrr+ri teauta�le�fi�A t�l`trd 20 Wrt con5trsuctimi to the follonivw,
10.Static water level below tarp of CSSIB r 28 (M) 6hislon of Water'Rc�ourcm Information Fiveessing Unit,
df 1twer kwl k athow tYlft am"t" 1617 MOD Semite beater.Raleigh,KC 276"-1617
11.sorthole ditrmetcr:6" (in.) 24h.Ea fnkWm hefty UYLY+ 1n aMition to sending the t'Orsn to the address in
24a above. also sarbtrtit a copy of this farm csiti in 30 days of contpletian of well
12.Well c+Otts MCdon UMbod:Air cemstsuCtionto the following:
tic.onger,nmm cable die ,pok etc.t
Division of Water Resoure&.UndeMmund Injection Control Program,
FOR WATER SUPPLY W'SLLS ONLY# 16M 141se-I Semite±Center.Reteigla,WC 2T6"-1636
134.Yidd(Upm) fi elhod of tat: tie.For Walter§KPDIY&In racoon Weals:
Also subadt otki Cop+c'of this ftyrrir %*bia 10 days of completion of
13h,f}lsinfctitiarn = Amettrn _ toad construction to ihao county licaltb dcp aMent of eta:County Wh=
Fmm -t PWMifiad A440M btr as