GW1-2021-02405_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD Far rlteerml useoxty:
'11[s forro can be amd ror simk of mwlipk%Vila
i
1.Vdi Cotutmetorinfomailotr.
� fs.'1►')l'A'fiR.�A
Will Reyes FROM TO oF,$m—IF119-
1t'e)1 coelraom Name It. ft.
4220 A
,.OU1I?R l3'fie2 Ssarcd�+e RtGII?F9i s Feab"
NG Well CaritxadorConiRtxtionNttrabcr Fit TO orAafF'TrrR T"WKNFM MATERIAL
SAEDACCO Inc ' (L lit.
CoMmy Narrae 16.`f >o1C OR> ING ►eesmrd d iio
FROM I TO I DI0IF.TEB I 1nlXVNTM INArt RIAL
2.1Vtf f Glnstt'acthln Permit#; ft. tt. �+-
tru.rli.ipplirame wrd pemrfra ox.Cm rnoy,$we,Variaee c,11*004 fry:;)
3.Wd l itse Wrock well use): f r
Water Supply Well: pRbM To pIALUUM + $10T yi TlncaCltim MATHtr.t61.
DAgriculmno OMtrnicipal/Mlic to ft. 20 ft, 2° I�' 10 schedule Opvc
043cothern al(HeatingCooling Supply) OResidentini Water Supply(single) ft. ft. ao
13bidustirriallCoummcial DResidential Water SuppR•{dialed) aQiROUT
FROM. TO MA4RRtA1. imPIAGf:MEYrA1L'iIIODRAM LiRT
Olrr'i lion 0 it. 6 tL Portland poured
Non-Water Supply welt:
�Morritorin ohccati ft. A.
lojec on Well:
DAquifcrRechargc OGroundmter Rcowdlation
FR M I To fAffrtrrAl, arrr 'T t':r n
AAtpofrcrStotngemdRecovcry OS.9linityBarrier 5 ft. 16 ft. sand 2a
OAquiferTca OSlon.w5a crl coinage
DE,ti mnatcntat Tmimology 0SUbSjdcncc Contivi o. Its (4 t tJ (.thsaalftn»ra tstaeete ifi`
OGeoEhtanal(Closed l..oap) Mincer FROM 170 VM0RirPG1% e0e1'ahsrft t>1hX*OPt, "ems
oGeothenual(HeatingCooling Return) OOtber(explain under#21 Remal&s) 0 f4 20, fL tan silty sand
4.Date Well(s)Completed.- 5-11-2021 WdlIDdMtr-4
n. h.
sa.'Well Location: n, (L
Dupont ft. fl.
Fact7itYon mrNomc Facility WN Cif appiicablc)
3500 Daniels Road Leland, NC Brunswick County, Leland, ft. h.
NC, 28451 Pk-skdAddmss.Giq'.Sad Zip :1t 1RRt1MAM t
Coua71 Paced (Inw)
Sh.Latitude and Lonotudc in degr m0mtrmuslfcc6nds or decimal ttcpnecs: 22,Cerfil"Motion.
0(ucii)ietrl,mt 1;+tAoas h srdneittn) *l�
34.316943 -78.034190 Wxre5 5/16/2021
stpmtarr of C lAci commdor hate
6.1's(arC)rite»sil(s): ;glFclmOteeM or D7ernporary fi srgniaX Ab farm;t lkem*y certiO rhm the u+d)jr7 wm 4worr)evmr.,rercd in arrourlmCe
wirh)5A NCAC 02C d11W or 1.iA ATAC 0217 A200.14'eff Comoraa°iton Smrdards and ilor a
7.IS thbo a repair to an odsting well: MV& or allo CcVpr nfdais Void w bem pmui"to ow+rrn on7wr.
tf;hb two oep41r,fftl oar bmm xtN<wnrrnarrirna]arjrraanmion and<xpfatn rbr earrre of the
repair andrr 21 mmrb-srr1wm or as rim bail'of Mir form 23.Site dtnnm or additional well detalts:
Yon may use rite back of this page to proiide additional well site details or well
8.IKtictlbCr of Heirs eonstftilcted: 1 construction details. You may also attach adt iti*mi pages;if necessmy.
Fo r lafe+crlar or firm-idler j wply wills ONLY"ith die Sam rnn5-hVcf m,yom rm S AL Ih'�(j�lT
Ion
9.Total'wedldepth below land surfam 201 (ft} 24a. Par Alt Wclis Submit this farm within 30 days of completion of well
Formtdripkwells fin oil erp&s fdir,-rmlemmrate=.s613(V'anal21@01') constnxtiontothefplhming:
10.Static water level below tap of casing:-8' _ _ _ _- _ {lit,) D11•6l0n of Water ResObrtm Information Processing Unit,
tf wrrrrr level italrare rvisiaaf.ere^s° 1617 IVIAH Service Cramer.Raldpti,NC 27609-1617
1t.Bare-hole diameter:6° (in.) 24b.EDr itntertlon'Wctls ONLY: In addition to sending ft form to the address in
23a above, also submit a copy of This form within 30 dm*s of comoction of well
12.'%Idl cofgroctton method sonic Construction to the follmArigg.
(i.o:anger,rolsq.cable"diw V sk sec.)
fttslon of Water Remenxs.` Ti dcrgmund Injection Control Progmm.
FOR NVATER SUPPLY WELLS ONLY. 1636 Mail Service Center.Ralefeb.1KC 276991636
13a.Yle1A Wm) A4cthod of test• � For Walter 5anals RrdnjaYloa tl,'clRe.
Also submit one cap}' of this faiin h•rtlnn`30 days ofcompletion of
13b.DIOnfection type: Anmunt- well constnrction to the eormty hc6hi dcpa tmcat of the courtly whale
csn�ructod. f
Fonn G%V-1 Nonh Camtins Dq munnn of Em fmnnxnl and Mrael Rewmas-Dn sign ofWater RIMirm Raised At1it 2011
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