GW1-2021-02167_Well Construction - GW1_20210721

s
E
i
WELL CONSTRUCTION RECORD Fa lrftma Use ONLY:
'Me(tm om be used for s1r&or mulliple t+r31s; �\
1.Well Contractor furortmatlon:
\ 4c. x►9ft1t 7.0 3
Zach Th son a 1. 'PROM Ao�rtrrrxr
NVOI t pniimw N2#* m`.�
4478A ft. fL
NC Wdl Coin morCenliksloii Ntanb« �U� l+ 2021 S G' i Yrtl 1. n .txr ttrab
ij�iZ FROM To A€AMMR ?ntt=W35 MAMMAL
SABDACCO Inc PCocesoo 0 fi, 274' ft. 6" is. Steel
G#. 34 litlittitBEt _ ,,L; . .
Cnritlu?nX'Ham pti�'� �-' < , .
PROA1: To DtAAMER I T[RCKA'M I AMAIUUAL
2.�Vcllrune:;it�ctionl'ermitt6: 2021-839
S.Wei ilsc(ci<odz tt�d asc?: . A,
WaterSu(tl€t}Wd1: PROM *M I:TAAMRIVIR I S ITZ "IMM M MIAL
ft, ft. In
DAgricul Ural ammi c pavmlic
Meetheaiml{leatingtooting Supply) gResiderdal Water Suppll,(single) fir 1a
(3lnd'pstrialfGom miai ORe ideatiatWaterSoppty(stmtrd)
FROM TO AiATBRiXt, HAfR1ACr off QD fi E Tii41
�hri' tell fit, fl.
Noo Water Soppip Well: tL
❑monitod 51]lteCoot
Injection , en: A. IL
OAgv1ftReeharg€ 0 roundm�terRemodiptioR _
oAgt►ifcr o€ c and itecowCT3' QS+'rlin )*met FROMMAri rr xci-r n
_ ti, fL
13 Aquifer test OStommidcrOmiAagc (t, 2
OEVcrimcn al Twh olog} Mutsidcucc Controi
2:<1)R2t NG� 1ii�A�ddittotiiiF ��f_
OGeoilmml(CioW I:orrp) OT acxr FRtssi m a. r 010t1. a rd"M toWftit
oGeothennal(Fleaur V Remmi) o0ther Cm bin under 021 Remarks) 0 f. 48' A. Sand
48' ft. 165' fL Gray Clay
4.DateWelt(s)COmp1dW* 6-14-2021 Wd ID#WSW-1 165' IL 198' rL Red/Gray Clay
Sa.Well Locatlnn: 198' (L 274' (t Re/Gray Clay w/ Sand Sized Quartz
Duane Stone Cedar Creek Fish Farm 274- FL 402- ft. Rock
F9c4l)Ow=rNuw amity t11R(ifappli;ibte)
ft, ft
7270 Matt Hair Road Fayetteville, NC, 28312 (} ft
Ptsysicet Atldcess t5b anili 2t.,
Cumberland 0450-53-3715 Open Borehole from 274'7402'
Patod 16to"llcouaft go.MIN)
31).lantifiide and"ng#udc in dcgrm0mlnutcttWcc6nds or decimal degrecr, 22 Ct rtifecatinn:
tit moil tkid,of c:tab'1oM is s dilcl�rd)
34.859574 jt< -78.810101 W 6/19/2021
SigmM€e of ccra ied Wdl Cavittae ,
6.Is(Nrr)1itCivdl�s): Permanent or U'Cetnporai? Xr signing akin fimm,l Arre6j-cerhYt Ads the vWI(t)kwo(#Wm)awn4fnWeid in aYata,&Wty
n1rh Mot MCAC42C.01M or iSA XCAC 7217 AM7 Well Cvws tru7t0n-&r nOffda vtOrtasi€a
7.Is this 8 r epali'm an existing Well: MYesor ONo copy ojrbir nv#a he4*m pmph rd to Ar%W1 vwwr
if tkla'is se rrpetl r,/lll arc€t welt e�srnrcrtcwa fn�m�eriiur and�sdoln she tttr€€€swe HJ the
n"nsrkrat*n or4m die bad o}ddi fir t 23.Site din);t�tm or gdditianal ell details:
You mavvse the back of ft pop 4o prmOde a flonAl"41611 site detitits of%tacit
t3.h of�clisaaustt~tcted: 1 constmu lomdeteu& You mnyalsositttiichadd`itionalpngesifnecematy.
Farm€xMlple irt/ectkuc.a€+rein-rr user AWphvelh ONLY nd€h►ie wmecombw4wym:era
xa�dn�lt oue J�iern. �
9.Total welt depth below land surfaces 402 � 24a. For Atl Wdlft Sut»iiit this4omi uithin 30 tl Lyl of lion of veil
For. rr7plenvflslistoideprksO'diperxnrte.ympie-MWmOZOl[a1 conStiieljvnto the folkming-
1b.,Static water ljwd below top ofcasing 110 (it.) Division of Water Resenttes,Information Pincesft'tlnit,
If MMr tavrd it ehOvs an al:#W"+" t617 Mail Service Ccntxr,Ratelor 1NC.276"-I617
11.Borehole diameter:6" on.) 24b.1 or[rrieetton MWb ONLY: In'addhidn to sending ttie form to the addmss in
240above. also grbmit a copy of this formi8ithin 30 da}'s of completion of Ovil
12,NArdj constnMdga rudbod:Mud Rotary/Air Rotary consimrcdon to the following;
(Lc:a ;dip.exbta dhw Vmh ap f
Division of Water Researtm 3Tirdcrgmund Injection Control Program,
FOR WATER SUPPLY 1VMA S ONLY: 1636 Mail stmnlece Center.Rani,NC 176994636
134.Vidd(gl m)25 iA4etltod of tcs1;Blow 2�c,For Water Sn t &In octhae Wdls:
.Also submit one to"of this form iitbin I d_,sefcotWetion of
13b.Dignfectipn hTO Hypochlorite Antpnnt: 1 lb #irell constroc4im to the caimty licitth depitment of the ciMinty.nharc
_ t:onst€actad. !
rona Gw-t 2013
Y