GW1-2021-07142_Well Construction - GW1_20211006

WELL CONSTRUMON RECORD for lttam I Use t ny:
We Fern am be rased for st&or,mdfi j c wds
I.Wedl6ulmetorInformation:
d4%TA
John 8isenman FRf)M 0 eaf1MV
U14'(4ritcLCtor'Nsirte
V .
4439A
1qCWdlC101lr2C40rC0rtiF"10nft1* r V\?(o' 7
er n lloo �affi►rfi�i#1 it O 1t+it 2. Heab
i31�3`tOR set" F"M 'M MAM M Ttrtc`tmm MAIMAL
SABDACCO Inc `V oV° 0 (L., 92 fL. 2" Ja. SCH-40 PVC
FROM TO I DIAMTM I Ti KIMNIM I MATERIAL
2.Wtdl VAnstruction Permit tt: 1t. (L hL
Liu ntl amfi r­Rpe'"do fl-r.Cc 5MV,Varinnc'r.:It eevard dr..)
tf. A. iaa
3.WO Use(ehcsak well ase)
Wat+erSupply Well: ►
6rt� 7rnc�nvslsS _ ArAtPRat:Ntt tr To _ DtAorRts:e sr DApkUltural omunitrpaymlic 92 ft. 1 102 ft. 2 lei .010 SCH-40 PVC
C)Gathenm1(Heatin ooling Supply) 011esidential Water Supply(sinj1p) �• �` t�
01odustrfalfContmetxiai Mesidendal Wain S eau To fATtiR[AL rati•L Art Ms
Supply(sha►t:d) nrVrttoo R AM604t
13firization 0 it, 87 fL PORTLAND TRMU418
NotrWater Supply wen: (L fL
roMoi►itorin E3P=cn
Injection Yell: fr;.
0AqulfcrLAcchatgc AGtsutel terttcf►►alialon 4 ,
IrN Ito'
OAqu=faSto O fATPR tr f!If rtr NrTLrOn j
rag cand Riwa't y ostalinittyAarrier 90 1t 302 ft. SAND #2
0AuniicrTt% 08tommalcrih;rMi;c
mKrimcntsl tbchnala QSubsiifcmtcc Cartrai fL tt.
2t1:;11 t31 '+dttaEl4ifitia f"
❑Geotltennal(Cloned Loop) Mtacer ROW1 To IassclLtr�nO s�kr tMewrtt t»a cti ,s c rx:
Mkoth imal(ReaggCoolig Return) I70tlrerti itt'ttnda#21 ReRtttsfts) 0 tt. 80 it: silt sand clay
80 R. 102 fL pwr
4-Date Well(s)Qmnletede 8-27-21 WeliIDOs-52 tc
Sm.Wert Low*":
Cleveland County Landfill tt fL
F9Cflft3i0%'MtN8mc FwilgTDN(ifVplicablO n. ft,
250 Fielding Rd., Shelby, NC, 283.50 IL
P1tskd Addmss.013 wA Zip 21::1t, 777,
Cleveland bentonite seal 87-90,
Conte; Parrot tAeMW=tloalto.(PIN)
5b.Latitude And X oral itude in doeStmi►utattconds or Occimol deg rem. 2L Certification:
(t(welt new,Ve tftrt)t slffJ&fd)
N W 9/30/2021
Sumo o f w_ D
,
6.Is(air)thcndl(ss}: .MPeftanent or aTempattns e ►*.✓ yy!!-<a—��y
NS sdgnai;L Jb1f faAiit, r',�r+�r.i/i!{,33.'sx�..i`:gsJ iJ,:S at'. L+arigtnrrted f+i apra„dmtre
.
whA HU NCAt:02C,';�- f ."`mot 6 : .L .ft30A t�efl Cnursrasrrslha Sa�ndarda on±i l a
7.is Ibis a t+ep ir to an existing well: 0YO or MNO u+�+s<+1 rhiv tr:n+rt Lr Pi►nddrd io the nrLt axaear,
If Msik a(epdr./1tf imt Arum uW eaax+u W m fiorrtwW and rA taht the Noire of rho
,t�iramdrrdsJ r�,arFa rreLrun ar na:tlu bark ofthf.,farar. 23.Site dhratn or additional well detalb:
You may use the bath of this page to provide addifiomlvell site details or lwel.l
S.1>,umberol'weib constructed: 1 canstntedon detalls. You imAy also siltacb additional pages if nemsat3.
Fornwgf}drLi,ftetW.or t-uwerAW i*gls ONLY with-the r+MeMnsbwffwu yawreoe
mr6atutatuefarRa ,SLUIMIMLINSST , NS
9.Totaltreit tleptli below land surfam 102 (R) 24s. F,or Ali Wells: Submit (his:!'Horn within 30 dsy%of cdmpktion of moil
Aornwl;ok xWit,R04 t ephs(fd Jfenw texaWta. MtN1`tract MOO) CCmsMiction to the l4tltming
10.Statie:water level below tote of t"uSt (ft.) division 4 Water RMa rces.l nfo mattion P eeWng Unit,
LfWaarr tr:N kdbMT cdah;,asr"+* 1617 Mall Serriec G 61ff.Raleigh,KC 276"4 1611
i
It.Borehole diatneta-8.2 5 0 n,, 24b.For insect S Wells ONLY—. in addition to sending the faint to the address in
24a abo e.also submit a,copy of this form within 30 days of completion of titil
12.Wctl rot+s4rsictlon mtahorl;asA earnswctlan to doe follwxhw
ti s sum.ramp.cubit dia huh cw:3 Mvislon of Water`Resosr+ct t Underground Injection Control PrDgrntn,
FOR WATER SUPPLY AVEi.1S ONLY: 1636 Mail Service Center*Raleo,NC 276"-1636
134r:'Yietd(gpm) method o€trst: 24c.for Waterr 5applf&Idectionveth
Also submit one copy of this farm trithin 0 ds sofcomplefion>of
13b.Disinilft on tops".; Amount: tt`cll construcdob to the coimry*health departmc nt of the coach wherr
c+onstructod.
FdnnG%V:t With CarolinaD defEadmunwamndNanallResou=s-Dit3ano1`N'afcrR40im RcttaedAim20f3