GW1-2021-04619_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD Farimtimol Use ONLY:
Tbis form con be ost:d for sigk or ronllipic utils
1.Weil Contractor Information:
Zach Thompson ROM � opsclur'no-S
�VcDCpnhm±mAmmlYamc !, rlOrf1 R. ft.
4478A c vi111 =
NC Weil ComranorCertifkmionNm�er r.r,���i^v11 ipro essing 'MOM CASING arotti�e*wdr* tts1Q taNTM K's &Ubtr
16tm.rit,.. � cE�t;Op moil To MA1,%1tTT9R TM -NFM I MATERIAL.
SAEDACCO Inc QJ�ViZ.. 0 fL 1 6' tL 1" ;a Schedule OPVC
tanvtm�rm�Nsrume 16.TfsNT'A ib7G R 1uB1NG' trsYderar etascd an
FROM I To I 91,0ITTRit I TTIWI VM I MAiER1AL
2.Well Constr artittn Permit#:
Liu all mpptirable writ permitx 10.claintr,Star•Variance.ft}s aq err.)
3.Well Use(check well use): 19 S.RifEN M
Water Supply Wall: oIAINWTRR, St T rn: VVKWK ssArt R-WDAgricuitutal G52vttinicipalmublic 1^ Io 0.010 Schedule 0PVC
DGeothe oral(Heatin&Cooling Supply) OResidential Water Supply(single) In
CltndusttiaUCtimnicrcial DResidential Water 5uppbf(shared) -S t3ROu
TROH I TO 1AT8RIAL HMPLA _ MMOD&AMOUNI T
❑irti Linn R. I (L
Non:Water Supply'Well:
A.
moron todp ❑hecmc
Injection Well: (L R.
0Aquift:r Rcchargc OGtomindmmdtcr Rcinodiatton i.1&*NI)rWA8yJ1L PAINCori f mAklt
'Far H RtATPRIA1. I?MVt A., r�rM1SrH n
OAgaifer Storsgc and Remrry ❑Salinity Barrio 41 f1. Ill ft. Filtered Sand #2
0 Aquifer Test ❑StommTecrD minagc
❑Experimental Twhnotogr QSirbsidence Control
20.nRnamca t „tr.�1��+►�trrn�atat+e�txtrr,�
❑Geothermal(Closed Loop) ❑Tracer ,Faust TO D68CRFMON m-or.errdn sowr4ett 13 titve"
❑Geothemral(Heath li Return) ❑Other 1 in wilder#21 Rernat�s (L R
n. rL
4.DateNVetl(s)Completed: 4/8/2021 WeJIID#TW-4
n. rL
511i.Weli Loeatirm: it. (L
Alcoa h. IL
FoetlehlGhroerNome Facility TDk(if appkable) ft. (L
293 NC-740, Badin, NC, 28009 ft. R.
Pllvskd Addmess.City.and Zip 7 it tAR
Stanly Bentonite from 0-4'
t;oamy Pated t-mirrcwtion Na.(PIN)
5h.Latitude and 1xviLitude in dc9miNminntc AScconds or decimal degrees: 2L Certification:
(if well i'tiktd,oar fd 7ong is mdfkktd)
35.309407 N -80.119054 W 4/9/2021
Sigrrrtam ofCcnifkd Well Cantractor Dare
6.Is(arc)The wCII(s): oPermaneat or oTemporaty
Sr signing rhir frrmti i Awn-by re►ri,/,v rhiu the n+rli(s)rity fwirrr)rnarrraeterl in axvotrbmce
;,*h 1SA NCAC 02C.01W or 1SA A'CAC 02C.02M WYrfl Conrtma-tlon Standards aril titre a
7.Le tbiv a repair to an tAwng well: t7Ves or NNo eppy ofthir record hear lwm provided ro Ar wit aaemrr.
if A is ix a rrWdr,fill tart knouw well r.onnnrafrm infora?arkm and etlrfohm the manure of 04.
ree"frtateder*11 remafft serf m ew rxm die burg of this farm 23.Site diagram or additional well details:
You m*,use the back of this page to provide additional ivell site details or well
S.Nitnmber of melts constructed: 1 constrrctian details. You m3+•also nnaeb additional pages if necessary.
For nt d#i,lnjelrik n or as-»arer sWph weds ONLY w h1i du same eansomflon.vo*can
submitow farm. SUBMITTAL=UCTIONS
9.Total melt depth boon land surfir ce: 11 ((I,) 24a. For All Wells: Submit this form orithin 30 day$of Gbtttpietion of well
For nwilop i*Wls list tell dt prbi(f differew feramipte-tte,w and 7€d1(,t,) Construction to the following:
10.Static water level below top of casing:- (k) Blvhlon of Waster Restiu tees,information Processing link,
lfwatrr level Iffibove mmas.asr"+" 1617 Mail Service Ccntcr.RAIdgh.NC 276994617
11.Dan-hole diameter.2.25 a (iu) 24h.E Spitxtloa Welts ONLY:r in addition to sending the form to the address in
24aabove, also submit a copy ofithis form within 30 days of completion of well
I L Well construction Method. DPT construction to the following:
ti.c.airy,rotor?•.cable,dime marsh ea.)
Dh islon of Water Rcsource�Udder ground Injection Control Program.
FOR WATER SUPPLY WXLLS ONLY: 1636 Mail Sen9ce Center.Raielgh.NC 27699-1636
13a.1 field(gpm) Method of test 24a For Watts Sopply&tnjoctioil Welts:
Also submit one copy of this fort mithin 30 days of completion of
13h.DiMrifection tyyme: Amount well construction to the cotmR tte:rlth department of the cutrnty whim
constructed.
Form(i4l'-t honk Carolina Dgmtmcnt of Ea itnm>wis and Natural Resoinces-Division of Water Reseirom devised Augi6t 2013