GW1-2021-02587_Well Construction - GW1_20210512

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WELL CONSTRUCTION RECORD "J Fer I tt mal vsc ONLY:
Tttis fmm can be osdlfar sft)c or mWuple mils 1\\
1.Wei)6nimetor.informatlow \
Robert Miller rst M b1-t:Rtprlq!i
\Ye11 Co+4nlctor Na►ne h. h, f
h. 7
2675-A
NCRdlCortrnAorCcr1fft 1nNmabcr S OUIRRCA_ ft ntv�mrH ORI1Ki.R 1tea6
owl Ta nrAt tFM TttrMTM MA7RrAr.
SAEDACCO Inc 0 fL as, (L 6° hh SCE-40 PVC
Cnt�tnrs.•NAarte
ls:1 rrj R;aua NG 'ot►ermtdeletrd4"
FROM TO I ouatrrtut I TntCi NTM I MAWRIAL
2.Wdi Conorucctlim Permit#: 0 h. 103+ (1. 2° SCE-40 PVC
lla 0114AWirriblr urff prAmifs ax.County.-swes'IroNalwe.11*6ari etc)
ft, rL it►.
3.V4dl i se(ckdc wOl use): x
Water Supply Wdl: FROM TO ptAJ tIVTRFt st drat: 7r11 MAt'Etttnt..
C1Agricalltntal 0141t11fiClp01i1'ubllC 10311. 108' h; 21 in' .010 SCH-40 PVC
DGeothemral(tieatingNCooling Supply) DResidential Water Supply{single) h
Dlndustrini/Con miercial DResidential Wtttcr Supply(shared) i IGRO
UT
196M TA ?4ATRRUIL EetPLACEhrSW 1.r MOD A Art OUW
01ni tion 0 h. 85, IL Portland Tremie
Nor-Water Supply lYeti: o h. 99, Ft. Portland Tremie
tSiivltwnitati Olt�m '
Injection Veil: in. tt
0Aquiferitcchnip OGmundRnter Romediation 14=,S
FROM
� nrnrrartu.- rrtiw� �tr.�rMr�ttnn
G1Aiittifcr Stomp and Recovery OSal ni»'8mrior 101' h. 108' 1L FILTER SAND #2
[]Attttifcr 7'cst O$tormw�iterlTrtittngc
0ExpertrtrcntaI Tvclmotog OSobsidtarc Cv"l A. ft.
U]tUAJNG7Atf dincl,tAd 1001141$ti Iif
DGeodiermal(Closed Loop) OTracer FROM TO 095MWTION osbr.r+aNn �a+mom AM ft)
DGeothet nal ti /Coofi Retum) Mther( lain under#21 Reram s) 0 ft. 108. (L
4.Date Well(s)Completed.- 5/5/21 WdI1D#TW-1
h. tL t y s•°�
So.Well Location: ft. fL � � - ky.j .w L-
Mt. Vernon Cubbard h, h. An �
Facility)0n,oerName Facrlity ID8(ifappiioabte) vFH
h. ft:
2930 Hudlow Road, Forest City, NC, 28043 A. (L �o;$vf!' �ili?fl ► af.£?�S!C3� izl
PlosicalAddmss:City.and Zip 21.1 ►1Axt S Y e
Rutherford Sentonite seal from 99-101+
t oatay Pared Ideteil9e;rtion 90,(PIN)
Sb.Uttltude and Lw ngftnde in degrecs/mimttcstiscconds or dechnal dc9rCes: 2L Q liftcatinw
(ifu-ellIkKone1>;ltdag S+ttllekill)
35.414702 N -81.912510 W _ 5/6/2021
SiBmtnre of i•:ad��a��- _ .�.
6.1s(arc)the wdl(s)* zPelmanent or oTemporan' s*6d+,K fo,,,, 1 hrmb}•certify flifAt flit NY1l{sJ xros�wrrt)curssnniled in dCfbllfdTle e
with 7 M NCAC 02C.01 M or 1SSA AICAC MC.p200 U ell Constn#Mon Smndtrrrla and theta
7.Ist63.ga repair toon existing well: oyes or MNo r-vFrr thErrrcurrdlarts4rralimrlrltufmthenrtlmower,
if ft+4s b a rgw4r.fill Deft fir►welt cowinnvion hTft anrinn and expfals the wwre r'rthr
nlartiraedert-71 remorix 8rdiw or on flit hrr1:atlas farm 23.Site diatram or addidovat weli details:
�You may we die back of this page to pttnide additional well site details or well
S.Number of wells constrncted: 1 construction details; You in ay also anach additional pages if n=saty.
Fro►muN#e,InicraoAi orWM-parer wFph bras OALYn�rh.duamityt+oastrurrla�r,yor
subndt Me foal. SURNUTIAL IN i1C17aN8
9.Total welt depth below land surface: 108 (fI,) 24s. Por A Welh: Sabnit this forum uithin 30 days of aotnpletion of Well
FortsAdtlplt wylls lift aflll V A7 cam unction to thy:foiimring;
10.Static water tcvet below-top of easing: (t,) Division of Water Rt:so'ureet.Information Processing Unit,
1f xalet kVe1 is aboir c J14,,1 ate"a 1617 Mall Service Center,Raleigh.NC 276h9-1617
11.Borehole diamettx:10.25^/6^ (in,) 24b.Egr init WO Weiic ONI M In addition to sending the fortn to the addness in
24aabove.also s*tuit a copy of Ads faun wilbin 30 days of completion of AwAl
12.Aral construction method:Auger/Mud Rotary ctntst uction to the lbQowilig.
tire.suet,rotary,cabit dirrd prash cftj
Division of Water Resource's:Underground Injedlon Control Program,
FOR WATER S11PPLlr'%TJAS ONLY: 1636 Mail Service Center.Ratet .NC 27699-I636
13a.Vidd(gpm) Method of test: 24C.For Water SapplS&Infection Wells:
Also subnttt one c'of this foma witbin-30 days of eontplelion of
13b.Disiufallon type Amount: well construction to the county health depadmcnt of the county when:
constructtxi.
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Farm('s11r-t Nodh Camlim Dagottrwo of fm mtimma anti Notural Resomocs-Dhsion of Water Resatroft Revised Aipg 2013