GW1-2021-07907_Well Construction - GW1_20211102

4'W.4LL CONSTR RUCTION i�ECORll For irtsmaI Use MY:
' nis Baum can be asod for sftla or 0110 k Mils"
1.Wdt Contractorinforinatiorr.
Stefan Smith_4 _ VA OM ngSC9rtPrrlJ.
A"Of Cortractgt'Nam, 01� ft, fL
a �a (L FL
3576A
NC 1'N'c)It o asurtorQ-AiCxationNamber 4&dmw Kati
l FROM TO Tm "'4FSS MA1E ML
SAfiDACCO Inc 0 r4 11 0. 2° 1n. SCH-40 PVC
e
t'6.1NNBtt IrIC"tTR: . G iie iaG . '::
Comsry NNW
FR M TO tltA:lfl?TRR I TlrtfAT'1i35 i JStAlER1AL
2.Well construction Permit# 0 (L ft
fiat 4011 trppiiruhle xr1lDe+ml)T ti P.COUM)•SM0.V'Adafece.11WCq dr..)
ff. n.
3.Wdl,tlsc(checlrwell ass±): 3 ..
Water$ttpplt WelkFR M TQ n/A�tP,T1 R Ysly TollGTtN1C5.4 MATMIAL
l�A&kultural DMonicipal(Public 11 R. 16 h= 2° l0 010 SCH-40 PVC
Mothetmal(ReatinglCooling Supply) DRe.sidential Water Supply(single) rt' in
OtodustliaMnunctrial 01tesidenfial Wait Su pp4,(shsted)
FROM TO MkTmuAL NMACr.M}t;V7 OUW
t7.tiYi .title IL ft.
Non-Water Supply Well:
Mmonitorin [7Recos R, ft,
Injection well: n,
0AotttfctRccl>at5€ t303roufidot+tcr Rcntcdiatian AN
FROM 1M I tun t, tsA11l,A iT1lftrtrnn
oAtiu a St07 c and RecoNVy OSalinity Dame( 9 fL 16 it. SAND 2
oAyuliferTcst 13Slomm7ttrr t)rttiTMgc
Mxptcimcntat Teclmotoz oSu bsidmcc 1coulml f L
10,0ttlFAAMIL a tiacb'ihtitierr4i5 e
oGootl meal(Closed Loop) oTmoer YROv1 TO oFsevttrnox oNov trwroin_- autvmcR �,�a ire
oGeodlemiai ft3eati blq Return) 00ther(ewain under#21 Remaatlss) 0 IL 7 tf. Silty'clay
7 fL 16 ft. PWR
4.DsteWell(s)Campleted: 10-1-21 WdI #TW-2 fL rL
Sit.Wen ocsition: ft. ft.
C&D Landfill ft. rL
Facility 0vocr Name Facility 1D#of applimlle)
R, ft.
4500 Old Holly Springs Apex Rd., Holly Springs, NC, ft. ti.
27539 Physical Addrass City.and Zip .,_21 tt>W►tAR�""
Wake Temp well was dry at install
Croak* Pxntd ldemirk-Arlon wo.(PIN)
5h.140tudc"and t.angitude in degr ecOminuta4sCClinds or titanimui d ,Certification:(ltti tilt tilted mte Want is ttrifithm)
35.664052 [fir 78.854243 W 10/8/2021
1"4
S �,._.,o , ,-
Si�l of lt3d�rcll taatfmcror Date
6.1s(are)the wtll(s)s tlP+ermanent or MTemporary Hy signing tha form I hereby certil}r than the uirlus)errs fwo m)rxanrtructcd!n&%Vtdantr
with 154 NCAC,02C.VIM or I SA NCAC MIC MA.M tVell CpnsteatWon Srnn&vds and chat a
7.Is th13 a repair to An od well; oyes or MNo tM-rofthis rearm how been prrvfrkei to t)rr%rtl owner.
if INS is a repok Plow twol t well c owmwd"h ommikMMd 0Wfain Ole,urrrre of dw
repair w dermal rmar*x sraim or nn.tits hrcrk of this form. 23.Site diagram or additional well details:
You nray use.the,back of this page to ptoc�ide additional well site details or well
S.Dumber of wells constructed: 1 construction details, You tug}•also Attach additional pages if tecemn-
Formiliple trtlerAvi or wm-»+seer nW*wells ONLY with Tilt wear consftwdon,y"eml
Mbndtelate jam+. -SUBMMLALMS31 C"1"I©iJS
9.Total yell depth betolc land surface: 16 (ft.) 24n. For At[ Weiin Subnmt this four vvithin 30 del}x of completion of n°ell
Formralliple wells list all dt7uhs ffdllp'errnt texAtaple•t 21gt aril 2@]Wrj con5huction to thefolloa*W.
io.Static water Im*1 below ton of casing; 0 00 Divh1on of Water Resaor'eta,Information Processing Unit,
If nntm k Mil is abort raxkp ate"+- 1617 Ma Service Ceatcr,iR*ld0l,NC 27699-1517
tt.Sorrehotc diameter.8.25° tin) 24b.For initrHaa Wells ONLY*'In addition to sending the font to the address in
24a above, also submit a cop: of:this font within 30 da s of completion of ivell
12.Well constr action method- BSA construction to the following.,
(i.e.suer.rota;y,cable,dinxg posh etc.) DMilon of WaterResollrm ndergfvnnd tojectlon Control Prog um,
FOR WATER SG'PPLY lt!RLLS ONLY: 1636 Mail Service Ccntcr,Ralelgh,NC 276"-1636
Ux Yidd(Fpin) MetW"of test: 24c.For Witter SoUlc&tnloction Wells
Also submit one copy of this faun %iMbin zit days of completion of
13b.Disinfection typex Amount: .cll construction to the county hchhh depantocnt of the comay when:
constntctcd.
Form GW:t NaRh Camtim DgmmwM of£mironawro and Nantral Resouloes Division ofVeraru Rewto R eAsed Al%Ug2013