GW1-2022-05418_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD For hacrmml Use ONLY: %([Field.0 #117
'Mis form can LV used far singk or tmihipk tcctls'
1.Well ContractorInformation:
'I4.WATRit ZONE
Stefan Smith FROM TO 0Fti('RIPt70\
Well Contrlclor Nnole � tt• ft. �
3576A
NC!hellContmciorCeniftait ion Nionber i,-0[ITERCroIN Tor"niuhieasedreRs 0R41Pt�R if-a lkabtc
FROS TO DIAMETER e THICKNECS MAtTRIAL
SAEDACCO Inc LFRON1
. 6 tl. 4•' in. SCH-40 PVC
C:otigrlit)t are RCASING4RXUSING eiilltrrmaltki►rd400TO DLAWTER •rIOCKNES.S MATERIAL
2.well Construction Permit a: . ft.
ldsl till applirable well permits pi_r.Cmtnh• State.1`ariarrct,lrysBort rr,:.7 .3.W'ell Use(check well use): CNWater Supply Well: TO DIANIf TrR` $10TS17t Ttut KIONS I NIATERIAt:
OAgricultual LJMunicipallhiblic 6 ft. 39 R, 41, in• .010 SCH-40 PVC
OGeothemtal(Neating,'Cooling Supply) OResideniial Water Supply(single)
Oindustrial/Commenial i'Nesidential Water Supply(slotted) �oC60U i Tt)f RIATFRtnL ! ERtPiaCF R1M RTCTnOa R ARIOtiNT
OIri •ttion 0 h. 3 tL Portland Gravity
Non-Water Supply Well:
ft. ft.
❑hlooitorin 0Rccm'cry
injection Well: ft. ft.
OAquifer"Recharge 06roundttaicrRenicdialion A9.SAND1t; AVEL PACK(it iAicabtr
FROM TO N1ATPRta1, F.RtP1 A('CAWN'TN"H(M) "
❑rlquifcrStoragcardRttoirn OSalinitrHarricr 5 ft. 40 ft. Silica Sand 20/30
❑Aquifer Test OStorrmvatcr Drainage ft. R.
0E\;per mcnt;%l Technology 08uhsidcrrcc Cotarol
20:'DRIfL1L1G':COG'faYtael+eddiliorinlsbirts',if► ,6mi•)i
oGeothernial(Cursed Loop) ❑Tracet FROM To IDF$CRtPT10\tColar hWron%s�w ilnsckH' ti tire.tic.)
oGeothennal tReatitLa Coolitie Return) 00ther(explain under f21 Rentaiks) 0 R. 18 ff. Tan 'silt
18 ft. 30 ff. PWR
4.Date Wetl(s)COmpleted: 2-17-22 Well M#RW-26 30 ft. 30 tL Bed Rock
5a.Wrt•Il Location: ft. ft.
Former GE Site ft. U.
Facilii)rOwner Nanic FaeilHs.IDk(if appli,able) ft. - tt. A d 202? -
1223 Fairgrove Church Road Hickory, NC, 28602 ft. ft.
Ptt)'sKnt alddmss Cite,and Zip 2t'R!MARtt$rt '
Catawba One foot bentonite seal fkom'3 to 41 "
(:earth' Marcel I&ntificvatuot ca,(PIN)
Ab.Latitude and i.ongitude in dcgrecsfminutcsAcconds or decimal degrees: 22.Certification:
(itws'en field,one Liblott i t:tdnckun
35.708712 N 81.260828 W 2/27/2022
Sigrur ofCek flcd�VcllConlrn:wr Dale
6.Is(arc)thewcll(s): 011tenmiment or 7Temporary M-signing this fifth,1 hereby cert fF owl rhr wellfsi uws{'.wire)canruucted ill&-carcltare
with/>tA MCAC 02C,010)nr 154 NOW 112C;0200 Well Consr1wrtirn Stnnlipds tint!tlHtt a
7.Is this a repair to an e%isting well: OYCe or ENo e-I)i of this reron'l has Not plkwid d to)he}n•ll Owner
If this is a telmir,_fill grit krimm well eoustmatoll)nforauttlon will eylahl rhr ra7rure of the
rel-wir tarderA21 a•jujAs.sr lion or an Me brisk of this farm. 23.Site diagram or additional Nell details:
You may use the back of this page_to provide additional%cell site details or well
8.Number of wells constricted: 1 construction details. You may also'attach additional pages if ftecesSary.
For nrWIV"infecthm cN mal-srimri r snppls hefts ONLY 16th rhr some eonsrnrcr on.yz}s Con
.wuNnir ear farm. SUBMITTAL 1-��1`)[QN-S-.
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Subnut this form within 30 days of completion of well
Far,ntthlnlr 1re118list all drpuht ifdifd re+n(eYmnp,tr••30200'mu!2e MY) construction to the following;
10.Static water level below top of casing: (n;) Division of Water Resources,Information Processing Unit,
1f uYiler level's alhmw oniag,ose"_" 1617 Mail Service Center.Raleigh.NC 27699-1617
11.Borehole diameter:10.625^ (in,) 24b.For III Wito Wells ONLI': in addition to sending the form to the addle in
243 above, also submit a copy of this form within 30 days of completioi►of well
12.Well construction method: 6.625" HSA / 6" roller cone Construction to the following:
(i.e.anger.rowan•.cable,dime push vc.t
Division of WaMrRcsouiyes;[Tndcrground'.Injection Control Program.
FOR WATER SGPPLV WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 276994636
13a.field(Rpm) Method of test: 24c For Water Supph`&injection Wells:
Also submit one copy of this form within W daps of completion of
13b.1)isinfectinn type: Amount: well commiction to the county'health dclinnmcnt of the county whore
constructed.
Fong GW-I Nwnh Camilla D.-Wnnient of Endronnicnt and:Natural Rcsoutecs-Division of Wales Resowces Rcs•ised:'lrgust N13