GW1-2022-03576_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD Far(MCM1 Irse ony:
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nis form can be used for sfMk or mWtipk aclls
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1.Wdl Contractor[nformation:
t it�l'A1'i B R 2@N E5`
Robert Miller FROM TrJ DFSCRtrTttDY
tYetfCviMcuCiorNau� R. R.
ft. R.
2675
NC Well Canmmr Certification Number fS QOTHIi(AS17Orir af�ltfi=eased"rYff ':ditGiNEII< "IIe16k
FROM I TO D6Att1ETER THTCKNM MAlMAL
SAEDACCO Inc 0 fL. 8 fL 4" In. SCH-40 PVC
to+uprh'Name t6lt�'. GQR tC0 Gi / iritclnied8a } .
FROM' T4 I DEAMRTER I MFCl:NESS MATERL&L
2.Wdl Constrmahm Ffereni.>
tut all oppa rrlrle 1,W]pen"its(F_c col mV.Sftnr,Varian r re.11*06 er.)
J.Wcll.i sc(erred:'aMl use),.
WitterSuppl3'Well: FROM TO MAW MI;t Sr:,0TSW -M-IC NRn MATRWAL
DAgricultival t7Maniciovftlblic 8 0, 34 rt 4" lie '.010 SCH-40 1 PVC
t7t eothennal(FteatingiC:ooiin•g Suppty� Mesidentiat Water Supply(single) R in
i$(iR@IIT• .
t71tidusiriallCvDrmerciai OResidentiat Water 5ttpply(shared) FROM Ira- TF RIAL I EAtVLACVWKW MEMOD A AM00W
nitn twn 2 (L 4 rL Portland Gravity
Non-water Suppty Won:
tt, tt,
❑l on0gnng 6aRrxas
rtyect sofa Dwelt: ft. k
C3Ac�rridsT Recirarg f30iour di Ater Rcmediation t .: d LP�t
rp IN TO I Mart; -1 abetFur r tux n
t]Agmf¢r.Stoiag¢andRccoyrrry 0Salinitrt 13airrieY 6 ft 34 rt. Silica Sand 20/30
17Aqunfcr Tcst AStvmM*&D aimgz
R• ft.❑ttV. CnMCntal Tmhnotogy. QSASidCucc�0nmr
lk-DRIGUI�@]Q�'r aiiaeliiitldlfitiead fe¢ets3r rrcce�esltni >
OGeotkimt.(Closed Loop} n7itretr FROM Td assCRTUUN eabr.hard" enrlhnctr Ne
❑Geodterttra[tHearir [il Retum) 130dxi(f inunder#2.aRema&s) 0 ft« 24 IL Tan Silt
24 fL 34 rL Bed Rock
3.Date Welt(s)Completed: 2-3-22 Well ID#RW-25
EL (L.
SR.Well Loc9thir a fL rt
Former GE Site tL tt MAR 2
fwiliryll]ivrtcrNamc Fmcilrry tDt+OEapplicablel M ft. Prot t
1223 Fairgrove Church Road Hickory, NC, 28602 0
DwQfmm
Fk!ied Addrms.City.nnd,zip 21 1 tCS
Catawba Two feet bentonite seal from 4'to 6'
040tmr Pxm d 1*01!Icvtlpn No,(PIN)
Sb.i atitadc and LnngRoO¢in mirm l �/Steonds ne dminiml d 1 ,d 22.Ceififecatioea:
(If%cell Aeld,one JaVloag Is Re RI&td)
�? W :.. / 2/7/2022
Sigitiuutri af�.:.a.c;:rt <<r ,<•:•ir• — DOC
6.is(Yee)the well(s)* oPernranent or oTemporary llp signing Pubs farm:l twreYt,tvrdY N diar the wel4s;1idY{yvtwj Gww&irered Lr 1&)vQIS I=Cr
ufrfi`I iA NC-4C 02C.Of09nr I SA NCAC OTC N 00 41eff C`ofrsfniMm Stowk ds wed tiger#a
7.iS this a repair to an tastumg*well: Me<i or KNO copy of Wr irrnni has br,m pmi 4,d to idle,urf1 inviter.
V rhla:lr it repor,fill oar Awmw Neu core malaw hrfbnwolkt mad expkbt rlte metre of the
repair amder 621 reiaarks m9eme or rut the hmek of tflir/nine. 21.Site diagram or additional well,detaib,
Your curay use the back of this pale to proy'ide addi,iorud well site details or weft
8.Nurtttrer of wells constructed: 1 coustruction details. You may'also attach additional pages if utcenan,.
For,mfilnple iY*rkn or ntai-+ewier rftppll Fvells b)VC1M uftlr the artnaea*ns#rwrtlaw,ww suet
xvbw„e awa{m,v. SQBMMAIL INS'i`C76;TIONS
9.Totall well depth below*land surface: 34 (f>t.) 24sL For ACC Wells: Submit tWs fain within 30 days of cpmptchou.of vvelt
For etas4lelawellstiernld,drlfrkrifd�rrrarefe��maplc:�2aTfl(1'e,rftlzeean 1 construction to thefollnesing-,
10.Static water lerrl below toil of casing,: A) Mvision of Water Re ourees,Information Processing Unit.
ifniater level 1q dxive odt6q,um"4" 16171 itH Service Center,Ralcio,NC 17699-I60
It,Barchole diameter:10.625" (in.) 246.For Lo crra 3Vc1js ONLV,. In addition to sending the form to the address in
24a above. also subrWt a copy of this form within 30 daps of completion of%vq1
12.Well coostruction method: 6.625" BSA / 6" Air hammer Construction to the folloNviuge:
(i.e.auk rmfy.'sable diraalpaste*cj j
Dh-18lon of Water Rescer'ces•,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Miff Service Center.Raleigh,NC 27699-1636
I3-&Weld(Spm) A1¢tlrnd of test: 24e,For Water Sanlrlc&InteCt'dn Wcth.
Also subn-iit one copy of this faint crrthin 30 daysof completion of
13b.Dlalnt"nn type.• Amount:, rr'cll cvnstnrcfton to the County Health dCpvrtmaut of the C4W"'WWTC
constructed.
Foan GW-t North Cam%u D mnwnt of EmdmrmriLL aid.mural Revnumes-Whision of Water;ReSotro-- RcU%cd August 2413