GW1-2021-04153_Well Construction - GW1_20210827

WELL CODLS--RUC`TON RECORD rar In t vsc ONLY:
'this form can be owe far shUlker mAiple mils
1.Well.Qatratctor Information:
t4<nrA .ZD
Brian Ewing FROM- p . iVrtON
walcottCado I�Itw ft. ft.
fG ft.
4240-B
NC Wdl CommdorCca f cilIonNmitrr &1011 f3A . fNt;dfowiMiiticasrdtiens T?R I iIdER. ilcah
FROM TO WAMMY"PR T[tW.kNFM MAnRtAL
SAEDACCO Inc 0 fL 34 fL 1° is. SCH-40 PVC
Caisilinny Kati
it. CA571i1i;OR; iNG' tlei+nat dace
FROM �10 MAIERlAL
2.'Wdi 0"ns mctinn Permit# tt. ft. hL
List al)eppiirtamr,wellpemrit4(Le.C—tp,Smear,Vnrianre,14er6ln W.),
fl. tt. Fa.
3.W1dl Gssc(chock well use): Y9i,
Ulster Supply,Well: FROM TO :inAatsrml St Tstar I '"11 W." I MATR IA7.
DA91101tntal DMonieipaltPublic 34 ft. 39 fi. 1° 11L .010 SCH-40 PVC
MeothemW(Heating/Cooling Supply-) OResidentiat Water Supply(single) ft. t"
OindustriallComnicMal C31tesidenttiat Water Supply(skated) 14 tiitOifr ",
PROM I TO MATER[A'L E fPLA "r MUTMD&AMOUNT
Olrri lion ft. f4
Non-WatcrSupplp We11:
R.
Mlvtonitorin ORM9,1 f1.
Trajection
O Agutfer Rectt irge RGtoundnotcar Remodiation
pom
OAgtOrer Stomp and Acca-miy' OsMinily Barrier 39 fL FILTER SAND # 2
DAgoifcr%cst OStomTwKerbn6noogc R,
O1xptrdmcntalTvftolozy DSobsidenceCount❑Geott emal('Closed Loop) oTocer TO arAca ON g!Arairsa�DtaeotbemtalTNead fl Return E30iher lainmtder#21Remaft 5 t4 FILL SILTY SAND
5 fL 20 ft, sandy silt hard
4.DateWell(,$)CGmplded: 7-21-21 WCjtjp#TMrf-1 20 ft. 39 fL SILTY SAND CLAY MOIST TO WET
So.Wed tAication: n, n,
Residential Property IL t( ate'
Faciliiy�,ncr Name Facility MR(if opplkable) R. iL O
2379 US-70, Morganton, NC, 28655 to (L
Phisieul Addeess.City.and Zip si I �11111
Burke bentonite seal 30 to 32, 10131 W JR
CMMY t AWA ldeliO11=11001vo,MN)
Sh.I.atitnde:and Longitude indc ltnlmltests;eaindsordecimaldegrees: 2LCertifcation:
6tsictl Bahl,one Iatllong is WIltiew)
N W _8.6an,..EWi ng;— 8/12/2021
sigmtaz ofcertl nd Wei Co Doc
k t9(tuv)the well(s): aPe:rmanent or oTemporery
lhr aignlng thi:jotin,I hereby nrgJY tfiqu the niril{s)Kas-tNrrrj[vaarrnaeted in axvoaatmarr
with 14A NC4CWC.01M or 19A IYCAC 11?C;QMPWell Conslrw den Standards mid idwi a
7.Is this a repair to an eiriong well: Mes or MNo twr ofifift rtword tans berm vnsv&kd to Ar%ril onaier.
if)bf c h a n dr,fill carlawtmw&'ell C'"an"ton leor wiw and eclatoln the m1we of the
„)pair a rders?1 rmwrb sftWme or the b6A ofthisfarAL 23.Site diagram or.addllionAt well detalls:
You may use The back of this page to ptoxide additl"W well site details or well
S.Number of wells constructeil: 1 constmcdon details. You may also t ttaeh additional pages if necessary.
For ntandple lnj rW or non-water jV*nails ONLY%Irh lm+snare tonshvrrtlar.va+1 Can
se�mir aac forty yiMMA L M 7[T^I70NS
9.Total tsdl dt�►1B hetr�r iarzd�tzrfasxn 39 (tt,) 24a Phr All Wells: Sc4ilim t this farm %within Sty da•%of completion of Melt
For sW)lple w0s Gat tr11 drWk Ot doerent(rxa7iple-3C'20 'aW 2@.ill ) COnSM d en to the fottoning;
10.Statle water level below top of casing; (ft) Division of Water Rmurcer.Information Processing Unit.
t/WW ►level h dbt)ve edAf,aae^+" 1617 Mail Service(:inter.Raleigh,NC 27649-1617
11.borehole diameter:2.25 S. 241Y.far[nldxtion tiyrtts ONLY. ;in addition to sending life form to tk addles in
24aabove. also submit a copy of this fonts nithin 36 days of completion of u-JI
t2.Nell construction method: DRIVEN constluetlon to the fistlowbw
(i:c.a qw.uxat)•,cable dhd pask c1c.)
Ai<i.9ion of WatcrRa @unw,VaderW)und jnjentlila Contrdi lltegmin.
FOR WATER SUPPL iTL S ONLY- 1636 Mnit Service Cuter.Raleigh,NC 27469)=1636
13s.Weld(Rpm) Method of test Uc.For Water$0ppX&tnlcetkni Wells:
Also submit Otte cop}'of this foriii nithin`=t)days of completion of
13b.Dishnfecfton type: Amount- %rill construction to the caimm hcli th depaRtmcnt of the cou"where
constructed.
Form t"a1V-t Alonh Camlins t'epm mmi of EsOmniomd and Nannal Rcwtms-Dhision of Water Rtwtrtes Rc%iscd)u4,tst 20i3