GW1-2021-07140_Well Construction - GW1_20211006

WELL CONST'RUMON RECORD FwtntcrnnitlsctlNl1F:
'ti form can tv uxd kff,,sftk at mWflitle„vlis
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John Eiseman a M p , rPtraly
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4439A \'\'\ O 6 2oS1n9\30k R. rt
WC,:WWI COMMC4orCeRitmionwnrtrr peQE;BS V.-Oul 4CDAASMMG�orirliHt� liieelt ::tol@fiV�i. )!cable
MAMIAL-
SAEDACCO Inc �C+�Qt�3��R�� iQt1 0OM (L T53 O ft 20Ari1FfSRiO. SCAB-40 PVC
C"Vay NOW
FROM (I.
DtA4tr: ER TFIWKNBSS MAtEAU1L
2.i'4"+dl Conthucthro Pcrnlit# (I• tc
t"tlta)ewwrraw"uvtt,i rimas(7.t.(:mwvt Swr.Varia r.ft}t edcrf fir.) (t. 0. �
3.Wdl vise(check;well tine): 1
Waster Snppli'Vlrett: [Tfl
T09 .DrAMPTUft $my 07x, 'ttnt•<tic;,'Rss :aATM"t-63 ft. 2- ix .010 SCH-40 PVC
QGeothermal(Heatiitgtootiog 5`tip O �1Residetltatl WaterSUppiy(Single) ft
Qllldustriall ommccial DResidential Water Stlpph(slated)
PROM 70 MA9 PRtAl. 1MTMACEWM- 'M
OD MOD&AMOUW
111niggrion 0 ft, 49 h. PORTLAND TRENNIE
Non-Water Supply Writ:
ft. ft
Mmoltikorin OR=c. '
Injection a tt. M
[,7ftriferRechmge QGrounitisaterRerttedintiats 1p.
T tempi tPi �FITT R
0AgniferStomgcon;lRCtxvvW Malinityt3atricr 51 M fi. 63 ft, SANDAL, #2
DAquilcrTcsi ❑stori1matcrDwansc ft fi.
0EVCrimcmil`ixhmoloa Q"sidC=Ccrttol
OGeotheratral(Closed Loop) oTra= eRohr TO D GRtrRtON cstsr ba itligrtri' &4!6tk
QG otheand ffleatiMSLaft Ret'mm) 130ther(p n'uaderM ilematis) 0 it. 63 IL silt sand clay
ft. ft.
4.Date Welt(s)Completed: 8-26-21 WCHIDMB-47
ft. ft.
Sm.Will Loeathm
Cleveland County Landfill R. fL
FacrlitylourcrNam Racilit}Q7!@(ifsppi ablo)
M fl.
250 Fielding Rd., Shelby, NC, 28150 k fr.
P10sicat Attdtess.City,.and Zip . t;
Cleveland Sentonite seal 49-51'
C,c+ta+ti+> trArtd tttctatt3catlgn Nn,(P7A1)
5h.Latitude and t ngtmde in degrees1mimitc0seconds or decimal t)eg vw. 2L CeidifkS&n:
(if tso t f w one 10ons is gidfictcoi)
1\` W 8/30/2021
51i;MMta of &W."o Date
6.Lt(ate)die xell(s}, MPe mantnt or oTemparary �` �,ca•�
*Xfonuig Aft jw,,s, - ?.:r..EW fi....'.r<u='1.�c,'�;�vrs,r:eae,/.tWas7mtred,Lr oftwtittmM
ovirh MA NCAC T7 .'_4 5,<;1i'.43-0k1 Weli Ciafit Moron St andkvds endow a
7.Is this a repair t0 an Glwdng til: EMS or MNl1 +uFsfll fhfs aratai t+r+e)amohkd m rl�ardl travrer,
tfiks hit rf r,fldl,xat$iNvtcal uell emmWite"AfffimeaNtan:ararl o-;Platn the r%rrerf t'd"
rryvtirrk rr f remnr!t tuxa ar the 16,ret of thlrfiirm 23.Site dlagrain a addldonA welI AeWis.,
You may use the back of this page to provide a"Ifiiand 1MI site del U'Or'Vell
8.Nbmbtrof malls coftftntcfed: 1 eonstMCdom detailt, `You May also a t eh additional"pa if necessary.
For mdfilleFfaft6on at aon-%arer sW %Mils ONM"ith the wmr ronshw4r fw y4P*ra» t►il'1'I 171lSTIIt^17(1 5"
"Loa nt ow farm, SU—Mr M
9.Total vrdt dggll behm land SUlrfa= 63 {�.) 24a. For All Wells: Stdrmit this form mithin 30 days of completion of nail
i r are tatf wttls trai real Af a l ditfrrem(ernrt+ tf 3 ( `aset 2!E!#tftl construction to the,follou tV,
10.Static gates latt below top of casing M.) Division of Water Rcneitrtit.lninrmttlan Protesting Unit,
If%rt+rr hwi is a botT ea dn't.Mir"+" 16177 MA meninx Ceptrr,Raleigh,NC 2769 460
11,gorchote diameter.8.25^ (tn,) 24b.Di,Llawft 1}2 ONLY: in addition to sending the fort to the address in
24aabove. also submit a copy of t►is fowl ctyibio 50 dail of completion of titell
IL,%roll Construction method.BSA Cons'tiction to thelblloivillg:
ale. retW,cable,durca putt ek.) Division oftS'attw"Resottrecs,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mai!Service Cepter,RAMO,NC 376"-1636
13n.Vxt4d(spin) MethrA of test+ 23c.For Water Sa Ipjoepou Mclis:
Also submit oil copy of this forin viithin 30 days of completion of
136.Disinf ction ty1m Amount: 1%vell construction to Me county health dcpmtmlari of the coldly,where
constmmod.
Form GW-t Monh L'amlins ikwtm-A of Emironaoeni and NanuW Resomms-Dhisloo of Water ReiWLrM Rcvtxd August 2013