GW1-2021-05293_Well Construction - GW1_20210615

WELL CONSTR CIn.ON RECORD for laterml Use ONi l':
This form con be nscd for single or natlt iple mcls
I
1,Well Contractor information: _
14.WATER ZONE
Will Keyes . FROM TO I nFICRt1`I10\
'r!'di CL mmanr Kane fr. fl•
4220 A ft, ft.
NC Well Conlmclor Cerlificalian Number 5�n9 V Or F-R CASING(ror muhl-ciistvl wens)OR 1,Nim(if it' ncahk
FRoM To PTA31ETER THICKVIESS MATERIAL
SAEDACCO Inc 0 (L 10 fL 2" ie. SCH-40 PVC
Ca9rrp6"g h'aerrt 6ANAiEIZ CASING Olt TUBIPIC; `catlr tataf cursed Itfi
FROM TO I)ANtETER THICKNESS MATERIAL
2.WdI Construction Permit k: fi, A. hL
I"lrll,rlrpilirrihlc well fwnniej fr-r..Cnunrc,RuAc.Varirarer,1f#kdCn eye.) ft. ft, is
..3r�Ydl.l3se(Ch4Y'1i AATI1 n�}: t Z;SC,RF:EN`. ,:':-.-•. _... :-:, :\
Water Supply Well; FROM TO .UTAMI;TMI: I SIATSUM I TMIC KIMSS I MATKRIAI,
MAgr•ictrltural CimullicipalTublic 10 ft. 20 ft. 2" in• .010 SCH-40 I PVC
®Geothermal(Heating/Cooling Supply) OResidential Water Suppy,(single)
MnndustriailCommercial ®Residential Water Suppy,(shred) I&GROUT
FROM TO MATERIAL I ENr.PLACTy1fE1TtlEfitOP&Ar10IIrT
❑ltri tipn 0 ft. 6 fL Portland 'poured
Non-Water Supply Weil:
ft. Fall.
lMM0nitorin ❑ltecoAc
injection Well:
❑Agirifcr 1Rccharge f]Crotiritltm-afcr Rertwdialion 5—SANWGRAVEL PA 4 i tlkable
IROM nG _ MAT'Ill"Al. __ ratPtAC►;AiE\rM17lt tf
❑Ag1lifCr$t4>itge 9tAt112ecnArt3' q$alint(y 13arricr 8 R. 20 G. sand 2a
❑Aqa kr Tcst ❑'formate`bmina� ft. A,
❑Expctimcnial Technology ❑Sidwidcttcc Control
2A."Mil UNG LOG falls ch atldifi&nal slamiffacces5an-11
❑G.otltemlaliClosedLoop) ❑Tracer FROM To itF,SCKIMON (abr. sbc,tkm
❑Geothenual(Reatit elCooline Retum) ❑Other(. aitt udder 921 Reenad s) 0 fL 17' fL silty sands
17' ft. 20' fL weathered rock
4.Date Well(s)Completed: 5-14-2021 Well ID#MW-19 ft. fL
SAL Well L1tCatirrn: fL fL
Rowan County Landfill (L ft
Faclily Owncr Name Faclity IDN(ifappitable)
789 Campbell Rd., Woodleaf, NC, 27054
Physical Addrem City.and Zip `.2 L RAMIANKS,
Rowan Bentonite seal from 6-8'
Crranit rmrctl ld€aifi iWn No,fah)
5b.I.Otude and"aigitude in dcgirroftinuteslseennds or decimal degrees: 22.Certif-k-Aon:
fif%lell fiitid,t3irt IMolt is xrdTieicrA:t
35.755164 N -80.549522 f� � 5/16/2021
Sigmw.owc—cw�-Well Contractor Datc
6.Is(ar)the well(ky XIPernutuent or OTeutporary }h•aigminp salt faros,1 hereby rerrefy ihaf the wd4.o%vrs{Mrrr)u1ni-inrererl in 4Weam4rntr
rei7h 154 NCAC 02C,01M Or!A AICAC(Y?C.0200 Nell CoAl inn rion Srnrxirrr,ts surd NA,rA a
7.Is thL%a repair to all O drrhug well: ❑Yes or K No re py[If rhir rMnni has beryl Frovith-4 rn Afar w-Il moler.
1Jrhts is m re�ilr,,fl!rays krrinrw to-t11 eO+ASAAtrrvlOrr hrfnnAurrk,Ar errul rc�lndn Jie Autrmre njrlre
repair ramler 021 nvmuerks serfion or rme fie bta-h cf Mis form. 23.Site diagram or idditionat well details.
You may use file back of this pap to proA'ide.addilional well site details or welt
S.Number of well_.constructed: 1 construction details. You may also affach additional pages if iymessarr.
For mAiMple hgeahwi or arm-iiy. r y)ijph ivells ONLY wJrli the same cwrstrvr ,dv;r,you egret
subrniravie form,. CUBNITTAL MIUCTiON$
9.Total.well depth behlty land surface. 20 ((1.) 244L For All W'e11s: Suhnrii 11►s.form A6l"n 30 days of completion of well
For mohiple wells Misr otl rde'p;hv if[1(ferew(e.y4wi+te-Mfll a aoJ41 2;Ion) conSlnrction to the folloning:
10.Static water level below top of casing 7 (t.) Division of Walter Re'1aurres,information Processing Unit,
ifredAes level isadiove wising.&-<e"+" 1617 Nait SaTiee CJenfer,Rafcigh,NC 27699-1617
11.Borehole diameter:6" 010 24b.For jgj&nn frog ONLY In addition to sending the form to the address in
24a abm'e. also submit a copy of this femur Atiithin 3O days of completion of Avell
12,Well construction method: sonic consinaction to the folloMiLe:
(i.e.3uger.ralmy.cable.duet/push ctc.I I
Dh islon of Water Resou reea,Underground injection Control Progl art,
r 1636 Afail Setr'iee Center.Raleigh,NC 27699-I636
FOR WATER SUPPLY WELLS ONLY: � �
13a Yield(glint) Method of to t• 24e.For Walter Supply&Injection WON:
Also submit one cdly,%' of this Mn i tsithin 30 days of completion of
13b.Disinfection ape:._ __ Amount:_ _e, _ Avc1l construction
�`tr lction to the county i,161th d tnrtt epartt of the cminh,Avheae con-On Fonn GW-I Iv'•nnh Camlhu Dgnonlcm of Enviroanxlu and Nntwsl Rea arres-Division of%%latrrRe?soutm RcOscd AuSuSt'N)II