GW1-2022-01364_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD `-f' ForrriterwiUscON1.Y;
This form can be aced for single or mulliptc nas
1.Well Contractor Information; \ ✓✓✓
d ..'A9 t?
Robert Miller FROM n CRivrrON
Well coairwtorNarm
2675 fL
NC WellCommceorCcn ideation Nw*n ti.4)UM C&M,G fforirirrdi eased ti I re Wabk
012R,
w nTASKrM TMCr VFM MATERIAL
SABDACCO Inc 2 R+ 2" 1a. SCE-40 PVC
Conrpat Name 51tiTG 4R 1NG ticrTlisB ckrstdabo
O DUtTF.TRR TIIICt.TT� MA]ER1AL
2.Wei)Construction Permit#: fL L
Litt a uapptirVAN,u-ru pemrih to r.County,Staar,Varimmr,11tetv4 i rtr.)3.Well rise(cbedt deli nxe).WaterSapptyWdl: nUNIFTER stttTRW iirl 1W ;RMNAI,
Mgricultuntl 0munieiprsilftlic ru 2° 1% .010 SCE-40 PVC
Meotlemml(HeafinglCooling Supply) OResidential R7aterSupply(single) R'11
lm
clodusttialfcominarcial aResidentatt water Supply(starred)
1•IATHRM FROM TO EMPEACIDNESi'JdTfritOD&AWI L7hr
Ohti' roan 0 R. 8 (L Portland/Be to
Non water Supply Well:
R.
amonitoriP8 mccove
injection well: R• rL
QAtluiferttccharge DGmtindvmtcrRemcdiation 99: A TI X'AL2EC tf '
F.R ATTO MATFRwr, rt>tTm A _ rr al-rfi D
0A01erStomgc and Rescm-wy t]SalifftBanicr 10 ft. 42 A. Silica Sand 20/30
❑Agir)fcr`fc9 C)StouTmratcr Oraimgc
OEx;p;dmctuat Tochnotogy DStdtsidcnce Control
2o;nttn,LtAaLoc ;d(a�, ddifloast•txatsttMcesra
❑Gecthenrml(Closed loop) 13Ttu= FROM To DRSCR"O•r altr,a.Naes+trtirnxrs trare.erc
Meolhernmi(Heati lit Return) OOlher lain under421 Renw1m) 0 (1. to IL Tan Silt
10 R. 42 R. Rock
4.Date Wctt(s)Completed: 12-13-21 Wdl Ind Rip-1
6,
St.Well lamatlon: M ft.
Robbins Mill R. IL jAN H --
FacH010n�nerNsmc Fan7it)`tDB(ifapplicablcl (L fL
200 Kennedy St., .Robbins, NC, 27325 R (L
Ph skal Addre s Ciq:and Zip =9L It'ONAttt
Moore Two foot bentonite seal from 81 to 101
l ovceh' t 2md Idemi ieation No.(PIN)
5b.Latitude and Longhnde in degleatmimrteslsceonds or decimal degrew. 22.Cu4itiration:
(tt xclt t)etd,rote hMpng 1s Stdl)ticrA) i_�.�
W 12/16/2021
6.is(.arc)the Tvell(s): MPerinanent or DTemporary By s curt thr jolm.t hrrel j-crrt;fy thx the uwll(s)war(nrlrt conanteW In MwAmrr
nith 15A NCAC OW RIffl a►ISA XCAMC AM tVtU CotrjtmFdvn St4ndarttt and lima
7.Is this a repair to ion existing Well: oVes or ENo uW1 o wr.
If fh1t ix a mptd r.fill rmr kr imm well r.»wnwilm hTftawtlon muf raplobr the nature of dm
re.wir al der b31 remarks sr aim ar rm the bar&of rhb fast. 23.Site diagram or additional well details:
You may use the back of this page to prat de additional well site details or vre11
8.ltumber of hells constructed: 1 construction details. You may also iulach additional pages if ntressary.
For mdhiplelirfrrtkwt or arw-itwer jWfJy xYtlt ONLY"Wei the some eonshw don.}"ta» �1)Bl1il1'CAL IN�C7 tiC7 iONC
lubat taue fona, - -
9.Total well depth brim land s urfew 42 ((l,) 24a, For All Wells: Submit this fonn within 30 d81%of completion of melt
Farrae11 eweUtliftaUriepArfidWewnttermVtr-3@211D'wW2@1QT) construction to the-foltotving:
10.Ststle water Imlel beloly top of casinV (R,) Division of Water ResWrres,lafarmstion Processing unit,
if nwrer keel is above n eft ate"{" 1617 Mail Sere iee Center.Raleigh,NC 276"4617
1t.Borehole diameter:6" (in.) 24b.Fier ipftgon Welts ONLY: In addition to sending the form to tile-address in
24a above. also submit a copy of this fort %ithin 30 days of completion of sell
t2,WCII CA45tMction tmuhod: 6" Air Hammer construction to the fbllolving_
(Le.aa,ff m sty,cable.dbw post.ttC.)
Division of Rater Resources tTetder(p+oond IrtJeaion Control Propatn,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"4636
2•c.For Witter SoUiie&Injoation Welts:
t3a Vic(d($pm) Method of test: Also submit one copy of this form xlithin 30 daysof completion of
13b.Disinfection OTC � Amount: twit construction to the county hdailh department of(tic court ivhm
conuructa
Form Gwr-I North Camltw Dgwnmm of Em-irowro and NanoW Resources-Di0sion of Water Resomm Rcvbtd AtrgUst 2013