GW1-2021-02416_Well Construction - GW1_20210727

1
WELL CONSTRUCTION RECORD Few lakmal Use ONLY:
Tltis.fann can be mod for s ftk or ntW1ip1e wells
1.Well Contractor Information:
14:i1'A1B1tZONYS.
Robert Miller FROM TO I DKSt`R M" M
U10 Cotftc s Name
2675 tt.
NC Well CotalactorCenifim.ionNumbes 13.oUT R CASINGOar eaitrl•sa*d%v8 OR" Scab
FROM TO DIA.W..TER TtitCK\F.SS MATERIAL
SAHDACCO Inc 0 h. 95- R. 6" its. SCH 40 PVC
Convany Namr 16 11tNER'CAStNC OR 7iT8114; berrtl� 4aaoi
kRQM--
4* TO DIAMETER TIt1C7 NTM MATERIAL
2.Well Onistruction Permit#: 100- ft. 2" hL SCH 40 PVC
list allo* rnble wellptnoirs(ie.County.Ssatr.Vorianrr,1j&�*v;em-.) h.3.Well Use(check Drell use).Water Suppl Well: 77.
rOT6p7y: �1iCUMM MATi RI Is
L7Agfict)1tniat OMonicipaUPablic110' .010 SCH40 PVC
13Gootbemlai(tieatingACooling Suppiy) DResidential Water Supply(singio)
Olndustrial/Commercial 1
ORexiderrcial WaterStippty(stgtad) ti GROOT
FROM TO MATERIM. ENTPLAC11MLVT MrMOD 6t Air 0UW
❑tni' tion 0 n. 95' It. Portland/Be hite
Nan-Water Supply Well: 0 h. 94' It. Portland/ B finite
®monitoring ORe core
Injection Well:
OAgaifcr'Rechalgc DGiottndlraterRenxdiation 19.SANbfl.HA[ L1sA
FR Fl1 - MATRUIA1I 1{MPi.A PVTMt:T"D..
DAgaifcrS"c and Recowry OSalink,8arvicr 981 it, 110' ft. Silica Sand 20/30
OAquifcr Tea ❑&Q.111%% ter Drainage
ft.DExperirnental T=lmology OStbsidcrlce Control
n.
.rliuul mir�ree�lri,,
OGeothennal(Closed Loop) OTocet FROM to DF,6CR OC asirr.60441 h W)WnK t n dine,tit.
OGeothemiai fReathigCooling Retum) 00thef(exlAsinuider921Retnaft) 0 h 93' ft. Orange silt
931 h. 97' to, Rock
4.Darn Wenis)Completed: 7-1-2021 Wei1ID#Dta-10 97 r< 110 tt. P1fR
SM.Well LocatMn: (L h.
(,
Ftxl q-)'Chvncr Name Facilit)-WN(if aoplicabic) ft. fk
�+ \36k
7110 Sandy Forks Road Raleigh, NC, 27609 h, h,
Plosiwl Adlass City.and zip 2t: t3fN 1' T,
Wake Two feet bentonite seal from 961to\q u D\N"
C"My Almd 1dentirlw0oa No,WIN)
-
ft.LXtitudcAnd Longitude in degec s/mimitcslsecIinds or dcc(mal d 32.Certification:
Iltwel)field,one Wong 1s s+dt)ckta)
35.871321 N 78.623558 W 7/3/2021
6.Is(are)the wttl(s): MPerttlaneat or OTealporary 1h ii0mb thin form.I herchy ivrlh,that the mell(s)inn lwrrt)eva nsieted in&TOMA"re
with 15A ATAC 02C.0,100 m lSA KCAC;?2C.0200 V0 ConarmtWon Smndrods and that a
7.Is this a repair to an existing well: Mes or MNo cops nfthb,record ha twm pmvkk4to Ow aril ovner,
if lhts is a r.-Adn fill owlblobvi wtll roastrwwo"Fnfarmarimr and rsplahrthe turrare of dw
nyM.ir under 021 r morka xwAory or an thr bwl of this form. 23.Site diagram or additional well Amilm
You tuay use the<back of this page to pm%ift additional%vfl site,details or well
$.Number of wells coamcted: 1 e:oilstractiatl details. You may also attaeb additim al pagesifnecessary,
Formalrlple T*edmi or anri-wmer sWpl+r urth ONLY with thr srtrnrevrtrsrretettore,van ter C_ 1I111i1TTAE Ii11STi1�ONM x4mft aw fora. SS
9.Total well depth below land surface 110, {II,) 24a. Par Atl Wells: "Submit this form Mthin 30 dayf;of completion of well
For nwNple wells list at/depAs(fdt((ermt le!rtmyple-3@200'end.20IfKf) constmction to die folkmi ng`.
10.Static water level below.top of easing (it.) Dii-blon of Water Rrsot frd.Iaf ratation Processing Unit,
1f isvierkvrl Is abdur twsl4g,we"+" 1617 Mao Service Garter,Raleigh,NC 27699 i617
I
It.Bovel3ole diameter:6" (in) 24b.For lrniecdon Wens ONLY: In addition to sending The form to tiro addrm in
23aabove. also submit a copy of this fort*1thin 30 days of completion of%wil
ILWdiconstrtmdon. otobod: 6" Air Hammer eonsitnctionto the ibllourinx
(U.auger.rotary,cabie.dinxd push ere.)
Division of Water Rem rem ttndercroand Injection Cantrnt Program,
FOR WATER SiTPPLY WELLS ONLY: 1636 MAD Service Center.RAId9b,NC 276"-1636
24c.For Water Supply&injectbm Welts:
13a Y(Cid(g{Im) Method of test: Also submit one copy of this form`tr"itbin 30 days ofcompletion of
13b.Disinfection type". Amount: well constniciian to the county he th dcpa&wn of the c+ounV where
eonstructod. f
Form GW-1 PDonh Carolina U�astnrm of Esn ironnrru and Natural Resources-Di,islon of Water Re Rcrised Aigust 2013