GW1-2021-04155_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD F«Irtornal Use ONLY: j
'ilia torte can be osod for sftk or tmdtiple wds
1.U1011 Contractor Informatlon:
Brian Ewing FR Sr DMC$ tvrr
Ntdl C,iatittsttim 1�Fattte fl. fL �
R. tL i
4240-B �-
NCWd1CommaorCcrt11kmionNnnbc7 4.0111J?A orRncH �Qi3i 6 fI11 1 f. Sub
FROM To DIAD TMCK-,%TM MAT1 TAL
SAEDACCO Inc 0 (L 24 fL 1" ` te. SCH-40 PVC
Cattip Namr 16:1 tQGOR G� .,,
FROM TO DIA.MrM ni TCAT'rM4 M j , AL 2.W49EClnstraetion Permit#: fi. ft.
rauaf)gtyffryar xrlf prnwjh(r.Comr%Stow.Varioere.14we t rtr.) fa. n. in
3,Woll- m(ckek wc1l nsc): r7
Witter Supply VVLA: FROM TO I PIANKT90t i SLpT (iy, I 'tNiC7C1 M" I MATI;RIA1;-
OAgricultund i3Manicipat9lubliC 24 ft. 39 f6 1" In ! O10 SCH-40 PVC
oothermai(HeatingACooling Supply) OResidential Water Supply(single) ft.
OtndustrizKommenciat OResidentiai Water Supply(shamd)
FROM TO MATTn1tAL SMFI.A ME"MOn AA31"U
Obviottion ft. ft.
Non-WaterSapply'Wdfl: b1
mmonitoringQRcxC�ae
InjectionWeil: (L (L
0Agv*rRccharge OGioundmtcrRcmrediation y D
FROM To AlAyptyAl, RMPIAM,,!rKr erF( D
QAgWfcrSlomSyc and PecA im QSRCinhpBarrier 22 it. 39 ft.:. FILTER SAND # 2
C)Agiaifcr I'cst OStommlatcr Drainage
ft. ft.
t]l:aperrmcntal Technology ❑Smtsidtttce Cot"
2lK,DRIt G-1AC t+lisebdditioniitEbetetstf '
❑t,eattemtal(Closed Loop) Ohacer FROM To Dl+zscTa esarr�eNn eeo,+rsR n ett.
OGootherntal ffleati ijvRerum QOther iftlftin kinder#21 Ren mist 0 ft. 20 IL FILL SILTY SAND
20 f, 39 rL WET SILTY SAND �
f.Date Well(%)Completed: 7-15-21 WdIID#TMrt-05 ft. ti. "z" �IV v.
Sa.Well[mattion: fL Q.
Wit
Wehner Green h. fL C
FwUftyiOnnctName Fiscilit IN Cil'appItAki
201 S. 12th St., Bessemer City, NC, 28016 0. fL
Plo sicol Address.Can.and Zip 2t >tat
Gaston BENTONITE SEAL 21 TO 22'
Costar Pared idetnirkat►ou No.(PIN)
Sh.latitude and L, nglmdc jn degt eWatimatestsmonds or decimal dtrees 22,Certification:
(it�elt tietil.rorr N.Wlor)6 lx s�dflcicrd) tA.
N N —8.d, n E�►�_ng,, �1/2021
6.1s(are)thenell(s): L1PrrIrtanel►t or ZTemporary kt.trgning tMt farm !trrr[bj to rsly thtu the web(i)weal{nrrr)con"rueted&r K"nkwee
with 1:%NCAC 92C ARV or 15A NCAC 02C.OIOP IMI 6'brttmwrfw Standards and that a
7.Is thb a repair to an eziVdng Well: oyes or Mo ofthif word has drra provI&W rn 0w•nr)1 vanrr,
ff*lj It a mprdr,flU am bmrm u eft raps nwfmr 4ttanwrW and esphin the metre of rtw
n-*ram$i,rR?)remarft ortim or as dw burl of dds fhnn. 23.Site diagram or additional well details:
You'mm,use the back,of Oils page to;prmide additional nvetl site details or well
8.Number of netts constructed: 1 constmction details. You may also tiilach additional pages if oacessaty.
For mmhitdr tnAviion or nrat•wtater jWpJr wrftt ON(.1 a frA-tile tame consfiartkar,,vorr etas
anboxit~form, rq,u m A I�l &TjX=NS
9.Total well depth below,land surface: 39 (fr.) 24e, Fnr A Watts: Sabmit this 4drm ithin 30 days of completion of:tell
For moopksowtitsrafldrp#rf elifferem(evwftr-J@ZM`ond2e]Wi con5truction to the following:
10.Static water Imel below top of tasing2 (R.) tllvtsltan of Water Resouries,Information Protessing unit,
ff warer level ltabave rdib.rate'* 1617 Mai Serviee Cam.R21604 NC 216"4617
it.DoreltnM diameter 2.25" (tn.) tab.Err lnieOM Weih ONLY: Ib tuition to sending the form to the address in
24a above. also submit aL Copy of this form within 30 days of completion of%wil
12.'Wldl constrne0ou pldbod: DRIVEN colmmetion to the followrittg:
toe.mWr mtory•,cable.ditw pask cite.) DNislon of Witter Reeanr axs,Undergimound Injection Control Program,
FOR WATER SUPPLYIIT S ONLY: 1636 Mail Stnice Cotter.Ralclgh.NC 27699-1636
i.
l3a Weld(gym) Method of tam 24c.For Water Snn)rl.,)•&:Idectiori Wells:
Also submit one copy of this font Mthin;30 days of completion of
13h.Disl(tfoetion tyTse Amount tyell constnwtion to the county health dep,mncnt of the caamly whoa:
cortomcted,
Farm G%v-t North Camllns Del mtttm of Endionmev and Natural Resomms—Di%kbn ofArata Rewtrtn ReOsed ArVd2013