GW1-2021-07908_Well Construction - GW1_20211102

SELL CONSTRUCTION RECORD
For Trtsrrwl use oNty.
;. Tbis faarn can be used tar si to of raw iyk%vV%: :�>
t.W41 C intrmetor informations Fl '
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Stefan Smith b0�`
� MOM 'tO Drs,SfYtlVriiFi,
wdkCor> crur>arnc At '� g• [t.
3576A
NC Well CanumorCenilkstion Nunber3.OtYiF t t3 raitrFit.dtxed�s'tt t?it"3 iNf�€ "8catite ;
FROM 70 �Rlxc
.TFft TR(CRIMS MATERIAL
SAEDACCO Inc 0 (L 16. In. SCH-40 PVC
Curry h'arrte #6.1
FROM TO DL►MF79R TRrCA.4£35` MAIUVAL
2.Wtyt Construction Permit
Ust all npplfrn 10,$wff prnff-Ox(Le.County,ShM Variam-r,Irftff of ear:)
fL fL he.
3,Wdl,Usc(check well aso)
'Water S'u h'Rrett: FROM TO larAMETRW al TSITY T"T M MATRNJ t,
pp DAgdouittrml 16.5R, 26.5 ft; 2- ira; .010 SCH-40 PVC
C�MunicipmilFltbtifr
Moftn mal(ileatir%Ceoling Supply) 011esidrnfioi hater Supply(single)
131mdtfstrialf0mtir rri tl 01t.esitfeornrl Water Stet}(sinned) FROM TO A n ATMAL FMr n&AM uW
13blilmdon tL M
Non-Water Supply Wen:
Mmantiodp ClRo or
Injection well: f►-
0+trttri1crltcrgc gC,rotmfalaaterRemediation AN ,.,t. to
QAtptircr Stor txo
rgc and Rvery QSalinitt Hamer FR nr MATE 9M. RMry afTl�tmtvTtl! n
15 R. 26.5 fi, SAND 2
❑A 01ter Test OS(orm ;wtcr 13i nagc
R. fL
❑ever mcntal T=hndf0,v OSrdasidcmc Control it►t)RllslAtcfiTAG eitacM ddltinas#shedsi(a it ir►
❑Geodetttml(Closed Loop) oTraeer .FROM m DmsscRrtrrrux crag A. YbWhick n 4ta)
oGeothemml tiMLaolll18 Return) 00ther{ main under#21 Remmks 0 JL 7 ft. Silty clay
7 tL 27 (L PWR
4.Date Well(s)Completed: 10-4-21 WdIMjTW3 (, (L
S&Well Location: ru it..
C&D Landfill R, tL
Facnlitk'MwwrName Facility TD#Cf epplicahtc) fL ft.
4500 Old Holly Springs Apex Rd., Holly Springs, NC, R.
27539 Pfi3icanTAdd�ssCSh-and2ip 3t.#Cl2St tt$
Wake Temp well was dry at install
Comity Marne(lattd4 :01101a No.MN)
5b.Latitude and Longitbde in degrecOminuto#scenvidsor decimal delpvm 2L Certification:
(it NNotlt$i Konel onsissfrtltdotd) [
35.665758 11` 78.855731 stye ` 10/8/2021
si�i otGc.Aw_ Well Conimcia, D*tc
6.is(orv)the wtfl(#): aPemmem or 01rxnporaa}
ltp.!$brot)ng rhv/axm l hkre{i}•errrd{,r thyt the nwlt(s)was{rrrtr)tvowtunerf irr acYorda»rr
ayttt 15A NCAC 02C.0100 ar 15A NCAC 02C.02M Melt Corrany Mon Smndtnd and AV a
7.Is this a repair to an wiMing well: Mes or M t nifty of flih rrrnnf fats hem prmvfrkW to4v NMI nxner.
If this is 0 repair.fill iml St(M'n tart!M wrtmeoon i4omartfron and r_trbaln the rmntre of the
reWir wrier Alf remarks serrialtr or rxt MW hark of rltfx fnrm 23.Site diagram or addltionat well details:
You may use the back of this page ito pro+ de additiothit well site defogs or well
ti.Number or wells concreted: 1 colts metion details. You tnkv also Mach additional pages if r►eccssan.
For Mufa foe Ive t7fwr or°Rim- arer JW !y wrlfs ONLY with the anima eansftwoo".cow rim
"Onft~f0m &UBM TTAj.111'S111t"_'nMS-
9.Total well depth behm land surfatc 26.5 {�,) 24aa. ft A Welk: Steamit this farm mithin 30 ikvt of completion of well
Fps►mriftlpfr wilt hir all derAsIfd*renitemyfr-J@209*an2@IMI con5tntctiontotk,f9ltowin&;
t0.Statlr s,ater le# belovr top of+.using 0 (h) Division of%tcr Rcsobrtts,,InformationProeasing unit,
If ri wer level is above eta*g,use"+,. 1617 Mail Service Center,Raleigh,NC 27699-1617
##.tiarrhtrle diameter:8.25" (ia) 24b.Fhr JaWall MWIS ONLY: In addition to sending the form to the address in
24aabove.also submit a copy of this form within 30 days of completion of isell
12.Well Construeft"Method.BSA construction to the Moir ILZ
ti&at cr rttnay,tanbta din dind grail etc:) Dli#.4lon of Witter Rcsonnxs.Underground Injection Control Program,
FOR 1VA.TPR SUPPLY`N8TLLS'ONLY: 1636 NUB Service Ccmtr.Ratehplt.NC 27699-3636
13a.Yield(Mm) Method(if test: Far Watcx SnpPiv&Itrja:tion Welk:
Also submit one copy of this forth within 30 da3s of completion of
13b.pitin&*0n. Tc Amount will construction to the county hcotth department of the cmnty where
conoructed.
FenrmG%'vl-I NanhCmtalinat7kepwim atofEmimnitrntandNaturalRewtirces-D isionofUlsterRewoes Rcvked,AWtzt2l)l3