GW1-2022-01328_Well Construction - GW1_20220124

d. WELL.CONSTltUC7'TUN RECORD ForTi4ematUscoNLY:
This farmcan be mcd.fm single or mWfMk"fls
1.Welt Contractor infatuation:
t4 ti►`AA'@ zo lE&
Robert Miller rR M o .RivnO\
!N'ett CQF*MCW r7arlle R. ft.
2675 ft, ft.
NCWcHConnaaorCcnifimionNunta 1S,011 RR TNG.gait, OR,iTPif t-fii il�a6Tc --
mom 'm PTAONP.TER "WOW." MATERIAL
SAI3DACC0 III( 0 1L 35 (t. 2" In. SCE-40 PVC
Conw my Name iS.7 ti`QR-Tft$YN� t�etsmtlalisseA 1
FROM I TO I DtAri1P.TBR I mWK'B3A MAtER1AL
2.'VV41 Canstrwetion Perintt
List all armHr%&'-writ pennift fie.Cowuy,Sumo,Variarwe,I1#kdCn mr.,) f4
in.
3.Wdl Use(check well me):
Water Suppy,Welt: FROM To n►ns/err.R szArswr, •nnc� -ESS MAraalA.
DAgrkultutal CJMtmicipal/FubliC 35 ft. 65 ft 2" 1m . .010 SCE-40 PVC
Clt'seothefml(HeatingCooling Supply) ®Residential Water Supply(single)
Dind'usttial/Commetrial 011csidential Water Sttppll,(shaed) RSA
FROMTo 11ATEIUAL "PtAC MINT MSfi1OD Z AMouw
Oh Lion 30 (L Portland/He LDtAte
Non-Water Supply Well: fmm nitorinLnjcxtin Wdl: tl.OAquifcrRrth1rge OGraundnhterRemodinfon gr. MATAKIAl. NM"A,:k"i!Mt THOD
OAquifcrStomgcandRc miry OSalitutyBarticr 65 A Silica Sand 20/30
OAgaitcrIcst OStomm-aterVndnogc ft.
❑ir,Vmmentn1 Techmolog�v ❑Siftdcnce Control <`L' ti ttfacfiaddTffonietsMerAs9f�cc1�"
OGeothelnial(Closed Loop) OTmce FROM TO O SCIUMON nwv.eitrfn "Wftk typt,Ot"
. imc.cu i
oGbodeniol(Heau1 ofi Return) o0tbet(explain under#21 Remarks o tl 65 (L Tan Silty sand
4.Date Weil(s)Completed: 12-9-21 WdilDOMW-10
n. fL J r.
Sa.ttVcU Location: n, ft.
NC DOT (L M
Rwlity/Oumr Name FacrTt tDR(Irappli=bk) A. fl
5426 NC-141 , Marble, NC, 28905
Plrysical Address.City,and Zip 21 1MAI A R I os
Cherokee three foot bentonite seal from 30' to 331
Conroy Pamet Ickmitiraiiou No.(PiN)
5h.Latitude and Ltingitodc In de{m s1minutestseeonds or decimal degrem. IL Certification:
(itOtTl bead,one tat/tort is siiitkkfd)
N W 12/16/2021
Sig W oft is r�!11 i � -- D2k
6.is(arc)the well(s): aPer'fnanent or DTempora y lh Aignins data fy m,1 hem4,y eer*that Ar urlMs)wars{wriri cwrwmeted in oc±vmmrr
Kith 1 sit VCAC OX,0100 or 15A WCAC 02C.02W WeU Consrtrtalon Smndar*and that a
7.Is this a repair to an existing well: OYcs or MNo (eTirof thh word has°bem pt pMM to tax urfl on-ner.
1f rift h a tmdfr.flll v1 dmm"well comrf f m ofamwr3nn and r_tpfais Ow natYrr of rhr
sWwirmdrr#21 mmaKa snrtia>Q or an btu bark of'thb forae. 23.Site diagram or additional well details:
You map use the back of this page to provide additional well site details or weil
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Fo►tuwMplr/Verrksior rim-n wer twpplr uvth ONLY wtiffi dte armr conspWdo".yaw c+cn 1RAt1TCAl INC !1t'790NS
suboL taw fam. SL-- r I
9.Total well depth below land surface: 65 ((7,) 14a. For At Wells: Submit Ws form within 30 days of completion of omen
F'o►owtttpk nx/ls lima114* br if do tremi feiramp ,-3tp200'and 2 1MWT) con5tnlQion to ft fottowitg:
10.Static water level below top of castngA Division of Water Resourtec,Informstion PtoeesAng UM4
tf wumrtft el is atria emMS.ratf"+ 1617 Ma$Serviec Centcr.Raleigh,KC 276"41il1
111.Borehole diameter:8.25^ (in.) 24b.Eal lgkon W413 ONi LY: :in addition to sending the font to the address in
24a Above. also somit a copy of this form within 30 dabs of completion of well
t 2.Wc11 eonShVetion fnethod: 4.2 5^ t1SA construction to the lbllowing:
(Le.=Va.ruler}•,cable.diced push ex.)
Dh,Lsion of Water Resourcl's,'Undergrollnd Injection Control Program.
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Senice`Center,Raleigh,NC 376"-1636
13a,Vidd(Apm) Method of teat E4c For Water faatrplr liarinjection Wetic:
Also submit one cap} of this font wltlnn 30 days of completion of
33h:Alsinfcction tvp Amount nroll constniction to the county 1caltb dcpsmncm of the count ale wh
cormicted.
Fain GAL I. Nonh Crmlina Dgmuywi r of Eadmumm and:Natural Resources-Division of Wata Resources Raised August 2013