GW1-2022-05395_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD � Forintcnolilsc0NlV: O
,I r This form can be nwd for s4igic"multipk%cells
1.%Veil Contractor Information: J
94 WAIT R'ZONIS-
Robert Miller FROM TO Dk�l'RIPi1QN
11'c.tl Cnliti:rlxnr Narlrc
ft. ft.
2675
NC Well Comr oorCcnifiowion Number '15:011TFM CM NG-forinuhi•easid wens OR LiNF.R(it u lkilhk
FROM TO DIAMETER, TiItCKNi.SS . MATERAAt..
SAEDACCO Inc 0 it. 8' It. 4n in. Sch40 Pvc
Goilipau)'tank INNER CASING OR TUBING 4itbiWrnottl closed•tatip)'
FROM I TO I DCAMF.TER TIIICK\FSS MATERIAL
2.Well Construction PciTnit#: R. 4.
lrrt all applirahle ai•lt penrrits fi-r.Carroty.Styr,Variarwe.11tfs0a1 ot.)
ft. ft. in•
3.Well Vic(cherlc well use): 17i`S(1RlJ N
Water Supply Well: FROM I To DIAMF.TRR I SIATS173: T111CKNr;ls I MATERIAL
OAgricultural LiMunicipol/Public 8' to. 68' rt. 4" in. 0.10 Sch40 Pvc
OGeothemlal(Heil iopCooli ng Supply) 011csidential Water Supply(single)
©lndustrialfComnlcrcial pRcsidential\Viler Supply(shared) 1F �� TO MATERtAl. i ENIP1.ACEM"T 31l ttOD fi AMOUNT
[]Irrigation 3 ' ft, 5' ft. Portland Travity
Non-Water Supply Well:
n, to.
Oklonitoring 6dRIxoA cr)'
Injection Well:
ft. fl:
0Aquifer Recharge OCirouudnalcr Rcntcdiation 19.SANDM.RAV LPACK(tf i`dletihle
FR(1M TO MATERIAL F:NpI.Af.'r:AtE\11'MITt1Ol/
OAquifcrStortge and itttotcn OSalinin'Harricr 6' A. 68' A. Silica Sand 20/30
OArinifer Test OStortnyatcr Drainage A. ft.
OE%prriincntal TechnolM, OSttbsicicrlcc Control
`IO:DRR.LING"IAG:fattach'riddltionnl shMs if ticresNirA'`
❑Geothentlal(Closed Loop) OTrdcer FROM TO DFSCRtPTION iiobr.AllMnrl.Anllrmckh n3ua.Nt.)
OGeothemlal(Heatin r Cooliog Return) 00ther lex lain udder 021 Rematiss) 0 (1. 20• ft. Tan Silt
20' to. 58' ft. PWR
4.Date Well(s)Completed: 2-22-22 We11IDARW-24 58' ft. 68' D. Bed Rock ' 7
5a.Well Location: h. ft.
ft. fl.
Facility:+Own.r Nan1c Facilhy[DR(if appW.1blc) ft. ft.
,l
1223 Fairgrove Church Road Hickory, NC, 28602 ft. ft.
Plgsical Address.City.and Zip
Catawba One foot bentonite Seal from 51to 6'
('au111% Panel IdculificakalNo,WIN)
Sh.Latitude and I nngitude in deglres/minutcalscconds or decimal degrecs: 22.Certification:
(ifwen fwld,one latlor?g ir:Sldlicwnl) �
N W' _ a .-_, 2/7/2022
Sigr►vus;of�';c;:..:,rii;':!t•::<:i•:.✓ �"--- Dalc
6.Ls(arc)the well(s): -OPenniment or OTcmpOraq lh-eigninl:•t s,liam,I herrbY rrrt)fi!their the n-d)fs)stvs fttrn�)r-me fried in fleconlanre
u7tA i S,1 A`CAC OdC A!(kl tlr!Sd A'GIG""R>C+72M. /ti•f!CnnStrt+ttlon ffntLf[rt+lc irtui tlMt n
7.Lc this a repair to an existing well: OYce (Ir t8 No rrrynp of this tree nl hoc terra ptnrirt d rn)!n uvll oxnlrr,
if lhis is o Irl"le,fill rrrtr Mrnirea well consintrtlon btfowwrion anti explain rhr nnnur of die
Ptej rir carderA21 remarks tertian ar rsn dw hark of this form. 23.Site diagram or additional welt details:
You may use the back of this page to provide addi(ional%veil site details or well
8.Number of wells cons orucled: 1 construclion details: You'nlay also aitach additional pages if itm-ewia '.
For mtrhlple infection&navi-water slrppA'wells ON1,V 113rh thr some commsetion,yen ca-6
.'Utrntit one fnnn. S,1UBMIJUALINST,(l,CTIONC..
9.Total well depth below land surface 681 (f6) 24a. For All Wells: Subtint this fnnn within 30 days of completion of well
For trnritiple rcr•lis li51 all depOn 1fdlffcunv(exmnple•3@2t'i:)'oM 2e IMI constnection to the following;
10.Static water level below top of casing: (ft.) Division of Water Resources;Information Processing Unit,
lfwnter Iced is chore rwing,nee 1617 Mail Service Center.Raleigh,NC 276994617
11.Borehole diameter-10" (in.) 24b.For lj1jg(gg Wells ONLY: lot addition to sending the foal to the address in
24a above. also submil a cope 'of this four within 10 days of completion of well
12.Well construction method: 6 5 /8 HSA / 6" Air hammer co1131nlcliou to the following'
0 c.Noger.rotary,cohle.direct pusk etc.)
Division of Water Resources;Underground Injection Control Pmgrtiltn,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scn,lce`Center.Raleigh,NC 27699-1636
13a.Yield(grpm) Method of test: 24c.For Water Suppil'&injection Wells:
Also submit one copy of this form milhiti.10 days ofcompletioo of
13b.Disinfection type_____ _,.,,,,_ Amount: -._ weil construction to the county;health dcpammcrll of the couml)•.elude
- - -
conurrctcd,- !
Form GW-1 North Cwolim M7jnmhu of Environmcru and Neural Resources-Division of WaicrResotrtcs Revised rluguV 1-013