GW1-2022-01330_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD �For lttcrmt Use ONLY;
Tl�s formcon be owd Cm siit6le ortnnitiglowas
1.Wdl Contractor taformation: \�
Robert Miller FROM trq aaS(R"W"O'.ls
w'd)CorAMA x tiartK fG ft.
iG fG
2675
NC Wdl CornmaorCenifkxtion Nafter 15.OUTER CASJXG fforaniVK*Wrd n'eA qR liifN4_13t Jf* l)eablc;
FROM To D1Ati9'M SS MAWRiAi.
SABDACCO Inc 0 IL 103 fL 6" in. SCH-40 PVC
t6� N .OR.fl1S' Gi" emal.#tea
(omfaut3 Name FROM TO D1,nIrm iii1C Tss MAWRlAL
2.Well Construction Permft 0 ft. 110 fL 2" SCE-40 PVC
Lia aril opplimme urll prM is(I.e.t"rnrnty,State,ifarinncr,IrjC+1h02 etr:l (14 fL
tn.
3.Wdl Use(check well use): 11 w
Witter Supply Wdh FROM To DIAR2r.TrR StATS177 T111M, SC I MATRIUAl.
Mgtiiulniral om micipadi ttblic 110 fi, 125 ft. 2" hL .010 SCH-40 PVC
CGeothemml(HeatingCooling Supply) 01tesidential Water Supply(single)
dfidusttinKontmerdal 131tcsidentntl Water Supply(slated) 1 t;R0ii7
FROM I TO MATMM EttP1AC3.MENTMEMOD&AM VW
❑hri for 0 th 103 fL Portland/Be itchdke
Nora-Water Supply Well: 0 fL 102 fi. Portland/ B Zttbnite
mmonito6rt t7keeo�e '
In ettion Well: n• M
0Agniter Rcctrlrge QGmundmter Rcritediation
1AT►UTAt; fG1t A,"tr�T Mt TNO1I
DAW*rSlonige and RccoATn' 0SalinityBarrier 108, fL 125, ft. Silica Sand 20/30
l7Agt>)fcr Test QStortmat_er Dmina8F
0ExKtimcntai Technology QSubsidmi:Control ft. ti
30.11RilA./K6° d addlllrms.slteetshf�ri
❑GootheimW(Closed Loop) OTrteer FROM TO of clUFrlox csafr ttsi 9 seoVR;ca a arc Brea
OGecthenwal(RcafitiglCooliLt Retunt) anther(explitin under N21 Remadm) , 0 ft. 60, ft. Tan Silty sand
60' fL 125' ft. weathe'red rock
4.Date Well(s)Completed: 12-6-21 WdlIDODMrf-1
fL ft.
Sa.Wig lacithm: IL ry• JAN 2 4 2022
NC DOT fL ft.
F=ftl3umrNitme Facility ID#(if vmlkabki
il: ft:
5426 NC-141, Marble, NC, 28905 ft. f.
PlnskdAddms&Oty.ant!Zip 2t.:ftE NKS
Cherokee six foot bentonite seal,from 102' to 108'
Cowtsn Parses tdernitic.ttion No,(PIN)
Sb.Latitude and Longitude in dcgmeshnimteslseconds or decimal do gn= 2L Certification:
(if aril Sirtd,one iatr9ot>g i's!{g0)oiErd) —,�
TV W 12/16/2021
sigma,:P
�
6.Is(arc)the wdl(s): •Permanent or Iffemporary Ry,.1gni„F Aria form.l hereby a*reify th�ar the mrt#sl twi Ore")cmwnreied in atcvw4mre
%*h 15A NCAC OX 000 or)SA KCAL(i'.0.OZOP Well Cominw6m Srandmds and At n a
7.Isc this a repair toinexistingwell: t7Yes or NNo ratrpo{rhir.rcorrlhas�rmprr.~lrlerlrn (vortlmenv.
tf*b is 41 repotr.fiil out bumv)well roawm .vk*kr Nn atipn and eiWOOn the amrarre r f the
rtpnirrut$rrd31 ronari4r moan or raa rhr braeP ajtMr form. 23.Site diagram or additional well details:
You tray use ft bacl;of This page to prmide additional well site derails or well
S.Number of wells constructed: 1 conswction detain. You may also attach additiottat pages if necessary.
For maMpte lnfncrbn are neat-ware r supple wells ONLY n>i(h rite some eonsh wx1ka.vaat nn n iltiiiTl7 AL 1NSTEit^9"fONS
A0aftit'sae funs. S.�--
9.Totalwdt:depth below land surface: 125 (R.) 24a. For All It lls: Submit this form within 30 bays of completion of well
For moMplewelb list all Jepths{fdi&rearlerVIr 3@200'awl2e1f7J ctm5tnldlonto the following:
10.Static water level below tap of casinz (n,) Division of Witter Resources,Information Processing Unit.
If Muster to vrl is abase m ng,,use"4" 1617 MAI Service Center,Raleigh,NC 276994617
11.Borehole diameter:8°/6° (in.) 24b.Far IV Woom Walla ONLY. in addition to sending the form to the address in
24n above. also submit a copy of this fort within 30 days of completion of well
12,ttreli canstructiow method: 8"/6" Air Hammer commotion to the follouring
(Lt.anW.satiny.c9ble.diced pulL cic.) Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLV'%%TT LS ONLY: 1636 Mail Service Center.Raleigh.NC 276991636
i
13a,Yidd(gpm) 114etbod of test: 24c.For Water Sol jtls i Jecithin Wells:
Also submit one cop} of this fobn within 30 days of.completion of
I3O..Didnfect4nn tr{tr Anmunt well consiniction to the county' ticnitht depaeroem of the county where
constructed.
Farm GW-t North Caralins Drpmrmm orEovimrurxna and Natural Resources-Division of Water;Rescuras Rc%iwd Atosa2013