GW1-2022-02952_Well Construction - GW1_20220301

WEhL CONSTR'UC-110N RECORD For Internal Use ONLY:
7 This form can be used for single or muhip)c%cells
1.Well Contractor Information:
M WATER ZONtiS
Robert Miller FROM TO DESCRIPTION
1Yc11 Corcrraor i\ainc
2675
NC Well Contractor Certification Nwnbcr 15.OUTER CASING.fir'inahi cased a'clls{1R LINER it kliplicall =
FROM TO DIAMETER THICKNEI'S I MATERIAL
SAEDACCO Inc 0 ft. 15 n. 2" in. SCH-40 PVC
Corigraup Kaute [FR
:INNER CASING ORITUSIKG ewber'mal claseddaan
OM TO DIAMETER TIIICKIN SS M.ATF,RIAL
2.well Constivetinn Pelinit#: ft• in.
l.inanalprlirable tsrlt primits ii_r.County.Shve.Variance.Irea tiaq ere.)
tt. ft. in.
3.Well disc(cheep*ell use): :4CREENWater Supply Well: OM TO DIAME'MR' .tiIMSI%S TJOICKNIN'S MATERIAL
(fir\gricttttutal L7MtIniCipal/fltbliC 15 ft• 25 ft,
2" in. .010 SCH-40 PVC
013cothemlal(Beating'Cooling Supply) OResidential Witer Supph•(single)
DindustralfConwilmial I7Rcsidcntial Water Supph(shared) iA.GROITT- .
FROM I TO MATERIAL I RMPLAF'FNLtiT NETROD fi AMOUNT
O1rri ation 0 ft. 11 ft. Portland/Be to
Non-Water Supply Well:
A. ft.
6atvfanitorin+ Oltlxm'cp•
Injection'*Veil:
fl, ft.
0Aquifcr'Rccharge DGrouridwitcr Renicdiation 19.SAN0W.PA%'ELPACK(if llicaAlk"
FROM I TO I MATeRI,AI.L RMPI.Af1:11E\TMrr"oll
❑Atjuifcr$tortgc and Recovery QSalinity Harrier 13 ft. 25 f1. Silica Sand 20/30
OAgllifcrTcst OStomw;ttcrDminagc ft n
0E\prrimcntal Tcchnolog*, ❑-Nubsidcricc Control 2n DRIIiL1iM'LOG'(attach addition al sbects'if ec mi-tiry'
❑Geothetitktl(Closed Loop) OTm cct FROM TO nFSCRiPtlON(coUr,hodncr:wftnwklwa vtin
OGeothenual(HeatinilCoolinge Return) OOtlter(explain under#21 RemerAs) 0 ft. 25 11. Yellow fine silty sand
ft. ft.
4.Date Well(s)Completed: 1-28-2022 WdlID#TwP-3 ft. ft.
53,Well Locathin: ft. rI.
Food Mart #10
Facili)ANviter,Inmc Fociliir IDN(if appli able), n. ft. -.
1150 Virgilina Rd. Roxboro, NC, 27573 ft.' (I. f= 'IF ft `sJ r i
Lie„•�,�'W:<�i�.•�,`�.•.,-".; �JI'ji
PU%si al Address Cin.Ind Zip 21 REMARKS'
Person Two feet bentonite seal from 111to 13'
Caunh Paivel Ide nii6cition N(t.MN)
Sh.Latitude and Longitude in degrecOrninutcstsccondc or decimal degrees 22.Certification:
(if ssen field,ote i0oig is suMescril)
N H' 1/29/2022z�
Stgn�ture of :r a sN"�=-- Date
6.is(are)thewell(s): %)Pennanent or 0Temporar7 By sittiing this fi+r+n.I hereby rrrtife rhru the weft(v)axis j%wr)ewtwbmfed in trcoordime-e
with 154 NCACO'C.1U(kl or 1.I4 A`CACU.'.C:<]20!]lti'l!Cortsmmirm Start finals ruin char a
7.Is this a repair to an existing well: oyes or M Ntl rgty of this rrrotvl has Not pmride d to the pall moirr,
//ibis is a trprrlr,fill Iva knoNW well eotistmMotr btfornstrlon and eaplabt the wrure of the
re1"rir torfirr 021 rrvnarkrsrejimt or wt the hra•k ofthis form. 23.Site diagram or additional well details:
You inav use fivee back of.Utis page to provide additional well site details or well
S.Number of wells constructed: i consttuctiondetails. You uvw also attach additional pages if Ihxesshry-
1'or mrdrlplr q(e crlan Ot ar�tarrxrr anrjyrfr urfls tTA'/,1'vi•Idt'rhr some rnnatruNioa,eon corn
culrmirrnrJrrnn. S 1BMInALINSTUMONS
9.Total%Tell depth below land surface: 25 (ft.) 24a. For All Wells:. Submit this:form within 30 divs of completion of ww11
for rnuhiplr ur11slis+nit depths lj dlftivrni(Ca'mnpfr•;t6r201'oral 2t 1(kYt construction to tilt following;
10.Static water level below top of casing: (D,) Division of Water Resourcei,Information Processing unit,
if w net level is above casing,tide 1617 Mail Scr ,icc Ccntcr,Raleigh.NC 2 7690-16 1 7
11.Borehole diameter.8.25" (.in) 24b.Err Inicctf(m Wells ONLY: 1n addition to sending the fonn to the address in
24a above. also submit a copy of this folin within 30 days of completion of,well
12.1Yell construction method: 4.25" HSA Construction to the followine:
(i.e.auger.rimar�,.cable,direct piste ctc.)
Division of N'alcr Rcsouncs,'Undct•pmtnd Injection Control Pmgranl,
FOR WATER SbPPLY WELLS ONLY: 1636 Atall Ser'vice'Ccnler.Ra leighaC 27699-1636
13a:.Yicld(gpm) Method of test: 24c.For Water Supply&injectifin Wells:
Also submit one copy of this form within 10 daysofcompletionof
73b.Uisinfatiiin type:_ Alnnunt: well construction to the county hcahh dcintim�u of file colmh•.w1wre
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con5tnicted..
Fonn G%A'-1 Nlooh Catalina Upanincrit of Em imtuncru and vatnrtl Resources—ltivision of Wale Resources Revised AvguSi 2013