GW1-2021-04621_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD For lrterual Use ony:
Lids.form con W lid for,sivic m rnu1tiph wells
1.Well.Contractor information: 4.1
� 'ECEN ,,vWA'tit2R ZONE`
Zach Thompson YROfir TO otcSCSRn 0"1
ntra Weft CocID1 Name n, ft.
MAY 19 °��°�, n.
4478A
NCWc1lCordmactorCcnifrestrouNtunbrr IiifuTt73i�^II� pCGCt✓SSingUt141 fi.OtT1'ERCAS. G ortrndEi tl+rett W11Jltt:R tf' flcablc
pon SE-ro� FROM 'Mnc+etrrt R T"WKNIM MA7"rAi.
SASDACCO Inc ° 0 ft, 61 fL 1" ta. Schedule OPVC
CAe sryName 16ANNIMCASINGOR- fNG e+atlertmaictasrda
FROM I TO I DM%T. R I THWKNV.SS I MAIMAL
2.W+dl Construction Permit#: ft, n.
I.W all amp?mule writ im7mits(Le.CmrM,Suar.Vnriunre,ftiisc on rsr.)
3.Weil Use(ehc c well use):
Water Supply Well: FROM To I DIM49TIOt' St T$E7FI T111t9t11W MATRRIAI.
Dikgricultutul 0municipailPahlic 6' n. 11' ft. 1^ 11L 0.010 Schedule OPVC
OGeottiermal(HeatinglCCooling Supply) OResideotial Water Supph•(single) n. I rL to
01nduslrial/Contmercial OResidential Water Supph•(shared) 7;.4OR01i9
ttAOM I TO MATEREAI, LnTPt.ACF.MEWM£7it0➢fi AMOCNT
olmri ties% n. f4
Non--Water Supply Well:
Mmonitori ORecov
Injection Weil: (L (L
OAgilifer Recharge OGround%alter Rentadiation 19.SAN hC PA w,i icrihic
FROM I ftlATPRIAt.- K Pi.A. r•:�T MIT n
OAquifer Stomgc and Remrry OSnlinhy°Barrict 4 r R, 111 fG Filtered Sand #2
OAquifcr Test OStarmnvttcr Dminnge
OExperimcntnl Tcclmolo • 0S1lbsidcncc Controi
20.01MAA to• aitftch addlliongl hods ifatcecssAn'I ',
OGeothemwl(Closed loop) OTracer FROM To 098cTti IRON COW.Aartn liowvack tare,Ole.)
13 eothemntl fflcatit > oli Return) ❑Other(explain under#21 Remadm) R. fL
n. rL
4.Date Well(s)Completed: 4/8/2021 WdIID#Tm1-2
n. n.
5a.Well 1,ocathm: rL ft.
Alcoa n. (L
FacilbyMunerNam Facility IDO(Kapplicable)
R, n.
293 NC-740, Badin, NC, 28009 ft (L
Pinaical Addmss.City.and Zip 21.. MINK-1
Stanly Bentonite from 0-41
CmmM Parcel idemi ication)40,(PIN)
Sh.tAtitude and Longltode in dcgir:.Wminutes/tseeonds or decimal degrem 22.Certification:
(if t,etl tktd,one Lvlflotg is snl(icictd)
35.309407 N -80.119054 W 4/9/2021
51Sm1nm ofCertifred WdiCormactor Dale
6.is(are)the well(s): OPermtwem or oTemporary
signing tier fair.l Perch}•rerrlfi•that the n+rll(.e)was(week)camttmrted in axrorr&nar
with I M NOW 02C.010.I or 1 Se1 k4C 42C:t)IOP Wr(l ConstmiWo t Smaddrds and cleat a
7.Is this a repair to an existing well: 17Ycs or ONo eery r f dtit word 40 hr m pmvhw to iira krrlt rtxvter.
if iAis it n repair,flit oar.krtuttra wrAeooWntrrinn Ii*nwfian mrd explain rke narare of the
repair wtderP-1 rkmarks serfim or an the bark of this form. 23.Site diagram or additional%veil details:
You may,use the back of this page to provide additional Avell site details or%veil
S.Number of wells constructed: 1 coustmcu}ot►details: You may also mach additional panes if necessary.
For nwhilde Mjee;k er Arm-waterWpdy rtYlts ONLY with dtr same eonsftvdorr,uoa can
=bMa ame form. 511Bl1 MAiL INSTUCT IONS
9.Total vvdt depth below latod suifarc: 11 (ft.) 24a. Por All Weily Submit this fora within 30 days of completion of vlrll
For mairiplr rtritr list all deprkr(/different(eratrtajtlr>3@20•and 3k'II)fr) constniction to the f0flo%ing;
.10.Static water lmv4 below top of casing: (R,) Division of Water Resources,Information Processing Unit.
if rtntrr krtti ir+aaut r[YltiA;.Ala:"+" 1617 Mail Service C m cr,Raleigh,NC 276994617
11.Borehole diameter 2.25" (inJ 24-b.Far tnlectinn.Welk ONLY: in addition to sending the form to the addlm in
24aabove. also unit a copy of;tWs form within M days of completion of well
12,Uldl oonstractlon Method,• DPT collstmuction to the following:
ti.e.auger.rutats.cables dind pusk coca)
Dhivlon of Water Resources Underground Injection Control Program,
FOR WATER SUPPLYWELLS ONLY: 1636 Mail Service Center.Raleigh,NC 276"4636
13a,Vidd(gpm) Method of 24e.For Water Sappty&tn(rxa&riI Wells:
Also submit one copy of this fort%ithin 30 days of completion of
well cOaSbltctian to the cwmq health depamne m of the county where
cons13h.Dhinfectioti h p AI»ennt: well construction
f
Form GlV-t North Carolina Dgnmw t of Em-imrawat and Nanva)Rcwwms-Division of Water Resotrces Revised ALgtA 2013