GW1-2022-04489_Well Construction - GW1_20220509

WELL CONSTRUCTiON'RECORD For lmicrnalUscONLY:
This Win can tv used for single or ntallipic wells
1.Well Contractor Information;
4 %VATERZONIES,
Scott Hunt, Jr FROM To OPSCRIP"ON
ft.
Well COntractot Name
A.
4561
15.OUTER C tNG(floromdIt46*§edW0%;) RiLINWtifffilk like).
NC Well Coviricior Cenificat ion Nomber FROM I TO DIAMETER- THICKNESS MA11TIZIAL
SAEDACCO Inc ft. il. in.
'16.INNER INC.
FROM TO VLAMETER. nucKxF_ss MATERIAL
2.well ConstructionPermit#: W10300450 ft. to. by
Litt till qViii-eible wrItprnnits ri-r.Cowity—Stale.Varicallre,1J8CffCn rrGl
,in.
3.Well Use(cloccli well use):
FROM TO PlAMFTVR SIOTS171. TI1lCKN N I-MATFRIAL
Water Supply Well: ft. A.
OiNgticultural 0municilml/Ilublic
0Gcothermal(Heitingtooliq Supply) OResidential Witer Stippk%-(single) ft. ft.
OlodustrialfConinicrcial ORmidential XVi(cr Stipph'(shared) ill.GROUT,
FROM To MATERIAL. I EMPIACTMViTMrM0D&AM011,%'T
elm 9tion ft. ft.
Non-Water Supply Well:
OhfmtitorinG ORecovvy
Injection Well:
0AquiIer'Rcchargc ClGrourodunicr Rcructliaiion -19.SANDIGRAVELPACK-fif Alotilic able)
PROM To I MATFREAl. I P1#lPlA(:TA1XNVM1-r"00
0 Atluifer Storage and Rcco%rr,%, OSilinity Barrier A. A. I
OAqiiifcr Test OS(omvivalcr Drainage ft. ft.
0EV. crimcniaol Technology [I.Sirtisiacrocc Control
DRILLI
oCkothetotal(Closed Loop) DTtacer FROM TO DESCRIPTION(mbr.bardneci.
DGeotheinial WeatitLeCoolitle Return) ®Other vex lain untler#21 Remarks) ft.
n.
fi. ft.
4.Date Well(i)Completed: 4/15/22 Wel1IT)9IP-1 - IP-32 F==4 ft. 9=OCZ
re
50 Well[A)CAth) ft. I ft.
Holmes Grocery ft. fo.
FaciiiipOwncr Name Fachhy IDN(if appljuiblc)
A. to, �n�71 M"
4325 Sherrills Ford Rd., Salisbury, NC, 28147 ft. ft. 0 ;"'C"j
1!�i­'J
Pli.%sicol Address.City.and Zip i 7 — -
Rowan Used 2.25 direct punch rods to inject 12
coahly PAt%:Cl Idnilirocalion N('r(PIN) intervals
�J.
Sh.Latitude and Longitude in dr.gror.cOmimote_secondr,or decimal degrees: 22.Certification-
AM,one latloq i:zmdrj6ctd)
W 4/27/2022
ccitific-dwOlCollimclor Date
6.1s(tire)(lie well(s): OPermanent or ZTemporaq 11)5igililly INS I fierrbY errfify that the wrllfs)uv-v(wr")eorwincied ht tAoiliance
ii*h 15,1 oVCAC 02C,01(k)or IM AICAC NIC.41200 Well CoiftrTirri(en Swn4wils(rood Oult a
7.U this a repair ft)an existing well: OYc.% for CKINo -(Vy of ibis recoryl ha,%Not provided ta)he sn'll mcner.
If Ibis is a wpoir,fill trVir k)?r;1fV Ierll cm)-viturfinn htfomwirlon arid explabi Me twrare of r11r
relvir turtier P21 remarkv serfion or an Me&wk of this farm. 23.Site diagram or additional well details:
You miky use live back of this paje to provide additional well site details or well
S.Member of wells constructed: 32 construction de(alis. You inav als6altach additional pages if ficcessary.
For i"bliVe ilt(eirrlon or arvi-warer sjfp)>fv wells ONIA'ivirli fit,-some construction.you cin BMITTAL fNS1.LIC33ONS
xUblitit One form, SU
9.Total well depth below land surface. 36 (ft.) 24a. For All Well: Subinii this form within 30 days of completion of well
PorattiMple wells list all dellths lfdlft rrw(exmiple. 20 Im') constniction to the following:
10.Static water level below top of Casing' Division of Water Resources,Information Processing Unit..
1617 Mail Service Center,Raleigh,NC.27699-1617
lf�nywiee level If rtbo,,e clisifig,tat.
J 1.Borehole(liameter.2.25 24b.&rIIli1XflllllP Wells In addition to sending On..) .JIL g the form to live address in
24a above. also submit a copy of this folio within 30 days of completion of well
12.Well cormiruction method: Construction to the following,.
6 c.angm rmary.cable..din-a push etc.) Division of Water Rciourcc'%.UndergmundInjection Control Program,
FOR WATER SUPPLY NAFELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
134L Vicid(gpon) Method of test 24c.For Water Supply&Injection WcIts:
Also submit one copy of this f6rin within 10 daysofcompletion of
13b.Disinfection type __ Amount: well construction to the county' health dqnrunctil of the county when:
:
constructed.
Form GR'•I North Catolba LN-Wrionent of Envirowncitt and Nawral Resoutces-Division of Walct,Resourm Revised August'_N)I I