GW1-2021-04181_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD ,� for itr MI Use ONLY:
lh s form can be Used for siitdta os nniltivk nr.11s
1.Well ContractorInformation:
�°u��®
Rich Lemire <<`.�� �� FROM DF.SGTtth1T0!i
VI'dl Cua dtstda>r Kanae ���� R. H.
It. tL
2593A sit
NC Well ConnacrorCettirkmionNornber P p� C-jG MOW, it"rrtiittkascdi%*1 O11:I Reab
nJti? �,.' PROM TQ DiA9iP,TRR TAfCtmm" MAMIAL
SAEDACCO IncpL� 0 ft, 3 tl. 2^ I'm. SCE-40 PVC
Comp; yNang �+ 1 .1 NGOS Yh`(} ►errntAeio>edd
FROM I TO DtA.MrM TfHM'M MATMAL
2,Well Construction Permit#; tt. tl4 h.
lift al0applir"We WM permits(i-r.Counrp.Sin,Variawe,rallLorddt etc.)
3.Wcll.ilse(eltedt-cell use): 2? GR�1a
Water Supply Well: no" ITO Tt tClf IM MATRRiAL
OAgrkultitral 0munieipal/Attblic 3 R. 13 ft 20 In .010 SCE-40 PVC
DGeotheai(Tieatio& ooling Supply) 01tesidential Water Supply(single) ft. �mt 1n i
ilbtdustrPai/commercial (Residential IV;'ater Supply(sbmad) tAt3Rt)tiX
MOM ITQ MATRRtAL ITMr?ACEME%TMtt 0o d AMoUW
Ohti lion ft. e.
Non-Water Supply Well:
®Monitori pitecov �• �
Tnjectlort Well:
OAquiferilMiuge OGmtindvr tcrRemeditilian
VROM 10 rATOtatAt PI., 1r�iTMi tit D,
❑Agnifcr.Stornge and Recovery QSatiniiv Harrier 3 R. 13 Q. SAND #2
Dkinifer To OStonrmater Drainage
OF-VctimcntalTcebwkW- ❑Subsidc=cCorrm!
".0Att t�P1G tl smi releetildiiiotidt.�lreels f°:. rr
OCicothermal(Closed Loop) Mum vROM I TO DasCRlMON aio+N.rsfl rnntUCA a
Meodiernial(Nea' oo' Return) OOtber"lain under#21 Remadits 0 h. 13, tL RED CLAY SILT
ft. h.
.DatcNVetl(s)Conlplcted: 6-29-2021 WCUIDNTMW-3
h. fA
Sa.Well Location: tL ft.
YADKINVILLE REFUSE DISPOSAL SITE n. tt.
Ftaciilit'M unetwome Fibcility ID#(ifaspplimble)
A. tt,
707 Tennessee St., YADKINVILLE, NC, 27055 n, (t.
Plowiml.Addmss.Cf y.and Zip 2ri:tt"Pl,N- 1tit1
YADKIN 13ENTONITE FROM O'TO 3'.
Coomy. PWIMI califtcatfogNo,OM)
Sh.Latitude and i.ongitude in dcgreeslminutesfser onds or&dnml degrees: 2L Ccrtifmation:
(it"eft fieK(nx tAnom is sartlltietri)
It VY 4—L- 7/4/2021
Signttore ofGcrt r�4e11 Contractor � thnc
6.Is(am)the Well(s): nPemtanent or ZTemporary By sigaing dds ja m,r Army rrro rhdl the +4141 woy{Mtnl roaf tnered tat&vvy onve
with Im NCAC 02C.0109 or 1 sA NCAC 02C.0200 WWI Conometim ftnRmds and that,a
7.Is this ai repair to an exiviing n'ell: 01'es or W No rtrlrs n�fhif rarorrf hRsd4�r+s pmr&led ro rhr nvll aa+rer.
if Als lr a repm'r,fit marb6kvt well r'ow rrcdan lafomaarltm aart cWtoln the malt,of rAr,
repair underl21 n narkN vedim ores the bnr1:of thin farm. 21.Site diagnm or additionat veil details:
You nW use the back of this page to provide additional well site details or Well
S.Nomberef hells eotnstt'e"d: 1 construction details. You may also attach additional pages if necessen.
"dwatff uoneform a l trak+sror nrxi-rimer s>¢pJr tells t7Nt,Y n lth da a+rmt sesstmrtlorr.}far ea» A lNCY JC TONS
9.Total well depth below land snKace 13 (It.) 24L For It Wells: Submit this fonn Aitbin 30 days of completion of nrli
For smIlWe kr1ls!hall deptAr 1fdtfferew 1ermiple•.r@2Afi'artrl.2@/tldl') Con5tmi:tion to itae fotlovviig:
10.Static Water level below top of casing" 5 (R,) Division of Water Resatnrte.s,InfotmationPraeessing Unit,
if»viler kwi is above tVdfW.am"♦" 1617 Alan Service Center.Raleigh,NC 216"-1617
i
tt.lierehote diameter:8.2 5^ On.) 24b.For Initetitm We@s ONLY: jln addition to seitding tits form to ft address in
24a above. also submit a Dopy of ihik fottn'within 30 days of completion of well
IL Well constnretlon method.,AUGERS constmeion to ti1C MOMW
Ox.raipm rotary,cable:direct posit etc.) Division of Water Rem roes. Injection Control PrWvnt,
FOR WATER SUPPLY'WELLS ONLY: 1636 Mail Service Canter,Raleigh,NI C 27699.1636
ML Yidd(gpm) Method of test: Zia.For Witter Stift&tnjatior Wells: is
Also submit one c of this form within O days of conVetion of
lab.Dlsitirbe lon hyre: Amount: Anti consimction to the coimry lichith dcpn tmcm of the Cm",vthcae
constructed. f
Fmm GN-t North Carotins DganrmW of Emironriei srd 1latural Resomocs-Dh*Ion of Water Resotrees Rc%,Iwd AWpA 2013