GW1-2021-04180_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD For latomai tlsc 13N1 Y:
•fib form can be owd tar sink or MW Vq e,wells
1.Well.Contmetor Information:
Rich Lemire pR M. otstTetrrslla
\Ydk/;UiltrEttio/t�dme .®0c��i '� h. R.
2593A 2 t6
""i p\ �,�� V��� 23.b1t7'F.R, (ilC�tt'o'r.�nvfttasmlrle ,QR �N•f:R(M Reab
NC WellCowmvorCcniI1kMiDoNsu*c7 l ,�
FROM To D)ANlt TSR vPSS MAWRIAi.
0 R. 3 fi. 2" ln. SCH-40 PVC
SAEDACCO Inc
CmnEaary Naar O� J J 14.1' 1NG al 4000l
�' �� PROM TO DlA\tt?[BR THICK IPM MAITRIAL
2.%Vdt Constuttction hermit#:
t.ia or1 amum a ueu permits(LC.County,Saatr.NUrittimr,Itltwden rtr.)
3.Well Use(cheek well use):
WaterSappla Well: PRO&! I TO VAT119 Ot SLOT 1V '"I 15S MAT100A).
CJAgricultuml 0municipallPubliC 3 R. 13 Il. 2" Iv 010 SC8-40 PVC
c+otberttni(NeatingZooling Supply) Mesidentiat Water Supply R.
OCt ITL
i 1rrd'ustrial(Co inmrial OResidermial WatefSupply(shared) i8.t7Rt)OT
PROM TO MATER6AL "TPLACEMLWMrMGD R AMOIit!'t•
oirrig9tion h. R.
Non-water Supply Well:
Wivlonitorin ORcco% •
In ett on Well: R: h.
0AgniferRcchargc t7GmimdwatcrRemodiatian t -g At2 d
PR a. TO PIATRRILAL
quitcr Stmgc and Reeav`t} 135aiinn Aaricr wa. !r_YTMt71r D
3 R• 13 R. SAND #2
Mquifct TO o5tommnter Drainage
O8?:perimcntRI 1echnotm ❑Snbs)dtrcc Coroml R. R,
24:= Rif ti t#siiacliItldiiiv+M�tabc�rt+s ,
OGoothemal(Closed Loop) OTtreer FROM To Dti=scRrrrtDr o�hr pawn aa9t'eEft G
0Gbothetmal(FIe ooli Retum) ❑Otber( lain under 421 Remarl s) 0 R. 13, ft. RED CLAY SILT
R, It
4.Date Well(s)Con)pleted: 6-29-2021 WplljD#TMtt-4 h. IL
54.\Veil Location:
YADKINVILLE REFUSE DISPOSAL SITE h, R
r%CJMWxh%'ter Manx Facile-W#(if applrabie)
R. R.
707 Tennessee St., YADKINVILLE, NC, 270SS R. (L
Pksiml Add)ass C:ih,.and Zip 3t 7t1:MAItttS
YADKIN BENTONITE FROM O'TO 3'. .
C"my pmr a IAeta rim ou No.(M)
Sh.latitude and 1.onglMde in degrecsfmimatesksconds or decimal degrees: 2L Certification:
flf tmti field,one t*lofv is$tdntkfd)
11 1y 7/4/2021
Si�aamut vF Wa C ndta mr Dale
6.is(are)the weli(s): OPermanent or ZTeamporary g,t gaing thit fimm i herttr}•tv-tiv rhmtrhr rrlkn was twere)cx�ntranrred in aerord icr
with W NCACO2C.0100 or ISA NCAC 02C M0 WWI Const1161W04 Stumdrvds and the+a
7.Is this a repair to an a dsting well: oyes or M Nir cops of chit rrraM t>.ra darn prm&kd aa>i9r aril du,rrr.
tf this is a repatty.flll mt.brtnen well tro wMettan b ormodon WW rxptafn she aarure of to
re*r under#22 1 re marks serfiumor ran the hart of this farm. 23,Site dtagrwm or additlonat well.details:
You nuo'use the bxb-of this page 30_pwAide addttiotmt well Site details or well
S.Number of wells constntaed: 1 construction details. You una)•also attach additional pages if necessam
For,nwNple 1gj&A vi a mm-»vaver sttcply tveil)ONILY"Ith the mme t+wrsnwrdaer� rom
sw6mdt one force. S URNInTAL IN4.Tt)_MONC
9.Total wdt depth below Iand surface: 13 (fi.) 24s. For All Weds; Submit this;form within 30 days of completion of well
Forowf olr ietrlleiist ntldepahi tldif(erettf construction to the following;
M Static hater revel below tap of+eosing: 5 (ft.) Di\•iSton of Water 114WUrtes,information Processing Unit,
11ffntrr kwl b above rail#g,aze 1617 MAil Stnioe Center,Iblelghi NC 27699-i617
11.Borehole diameter.S-25" (in.) 24b.For iaWan Wells ONLY. jln additiion to sending The form to the address in
24aabove. also oubmit a copy of this form\ritWn 30 dms of completion of well
12.Well construction method;AUGERS construction to the following:
fire.>n.ger.story.Cabtr(Eno postictc) C
Dfv Iston of Wolter Rcsourccs.Uedetpround Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 16361liail Service Cemer.Rale o,NC 27699-1636
13a.Weld(gpm) Method of test: 24c.For Water Sormly&inlodfurr.Wells:
Also submit one copy of this form\\thin 130 days of completion of
13b.Disinfection ty)ae Amount: .veil construction to the county health deps t cat of the county Chen:
constmclod•
Farm G\V-1 North Camtina Mpm mmtof Endton vat and Nowal Resomms-Division ofWater Reugrtes Rcvkod AttgUSt2013