GW1-2022-05229_Well Construction - GW1_20220531

WELL CONSIRUCI'ION RECORD Fatfdx,,rdatiits4olvri':
This form can W'twil f&,single at mdtipk:Y%vlis'
1.tVcii:CtintractorLrtorma'tiou:
14.I1i\TER ZONl.S-
Robert Miller FROM: RO DF9tR/hltOX
Will CgJ%MdarN7m4 R• ft.
2675
NC Well ContmctorCcnif=tiof1Niucficr 15.OUTER CASING ORLINERiffai licybkI
FROM TO - DUCMTER THIC6N % 'tMLAU
SAEDACCO Inc 0 fL 50' fL. 6" iq, Sch40 Pvc
I'
Cora utp-N tniC .16.INNER CA-41NG OR TUBING`'reodheranat cluacd-lon
FROM To DIAMETER THICKNESS I MATEUkL
2,Wclt.C,onstr•uttion PrrTitit n: ft, ft.. '�4
List(rlla7icnblrvsrJl�rermits.tisr..'Cnrrnh,$ttrtr,,lrnriorcr,TrrfsYd'txlerr..J'
rt:
3,'WclLfisc(ChCCI.�'cll P5C): 17.SCREEN
Water Sitpllly SjMI: FROM• 1.10 DrAArF:" 5LOTSUT, TI#ICICNI $ MATE IA1.
CIAgIictlltltnll C?AllnieipaMiblic 50' fL 70' ft. 6" iR• 0 .02 Sch40 Stainless
®Geothellllal 0Heating(Co0ling Supply) 0RA sidential Water Supply(single) ft..
®1ndu5triaUCantutclnial ❑R idential Rater 5uppf} (shared) F81-RO 1 ' ' 70. DLATL'RIAL E1n'L4,CEIILNT IYIUMOD&A'%IGUNT
❑Itn'atitrn 0 ft. 44' (L Portland trimi
Non Water Supply Well:
q)vtonitoring.. MRccovrry
111jeclian Neil: ft. IL
❑AtluiferR.ccharge Mdroundts;ltcr Remediation 19.S 1NM'CR,#. eL PACK fir a i tllcalstet.
'RROht'' ' VTO I MA'rF:R AL Fi\a FIA(MMEYT10711100
(7AlatlifcrStora�eati ttccoz'cif' I]Stlinitv]3aiiicr 47' ft, 75' ft. Silica Sand 20/40
i]AquifcrTest 135(ormsv;ttcrDininagc ft, ft.
L71 xpd:rimcntai TcOinr ogy pSubsidcncc Co34gl
20i DRILLiNGLOG(aft ich adililionRI shLcls if bcccssnn't
❑Gd�otttenttal(ClusedLoop) ❑Tracer ,FR051 .TO DF4CRtPTIONtcobnnynfiic.,urR'nrck d s?e;tsrt
❑G odicinial(14eaiiigOCooUug Mum) ❑Outer(explain:wider 421 Remo&) fy ft
fL, fL
4.Da.t,:WeU(9)C4tnpletcd: 2/20/22 Well JD#EW-65
$a;Weil,I.Iicatitl0;: (L-
rL tL MAY 3 1 ZQ2
Fadnty�t'wrName., FaciMy IM"(it'appllcablc) ft, fL.
1248 Sill Hall Rd, White Oak, NC, 28399 ft., rL
f�b......
ter:,Q;1,0G
c�t��..ddndz�N =.21.Re1sIARli.S
Cumberland Three feet bentonite Seal from 441to 47'
Ctand=y Yarvelld;nlitrcRllvnNo;(PIN)
ab.Latitude"aud I.6ngitndc iD 114gmiVminukc Ascconds or dcclm'al rlcgtec3: 22.Certifieatini<•-
(if:AcCll feld;tvd IA10tz i:tiutlit id)
1� W 2/17/2022
Daie
6:Ls(ar)the well(s): mPermattent or OTcmporar}' 1lpadgirrrlE.rhii form;:1 hereby cerrifc.r/iot the ibis);:vx f arre}coavrucfed br-at•eardanre
withl5AaYC1CO2C.010V or.JSANCAC01_CA09llellConatrrrc6onStaMardsandilmra
.hthNanjdaleittnmeeiNtinj&,,p'clli I]Yc5 or MNo cviyb_ftAws rv�4 Ito;hriei1-�rovirfcdtra'i;wtir11-mer,
lfalrts'i1 a recvlr,fiN varkwoitw well arar1 eilrtraln die mrare of the
sera.ir mukr921 nvniirL-' iii a cream ilie bdrk q(rfiisfvrmL 23.Site diril;runr'ar additional well details:
you Ill ay-ase.tlit Uack'of this page.ta,prgvide'.addidouat well site;details or well
S.-N.Umberof wcus 1 constmetioif details', You inay also:atlaeltudd itional pages if necessary.
For rmaitd�e hrtcYafaurcnr nr,,!rattrer s�,rt!v'�c71s G1NGl'ivldi rlic.anme canatruitlon,}¢ur.cv�r
r viictur rMa: SUBATITTAL INSTUCTTONS
p.TOW ivc11 depth betov_land surfmcw 75 2Ia Fnr Al1.Wills. ,Suhrnil Ittis fuatia ttrilh%n 36 days of completion Of ti'elt
For aas+ilpleu=eNr 6taPl+ $*wsfftovewjt Yatujrlt-J@20o`war'12@1 )' constmcti0n-tmilafollotciiag;
10•Static outer levetbelow top of cmirkW. {fL) DIN-Wrin of Winer Resou rc64 Information Prdcessin!!Unit,
ifnrarvrJstrl il'ut rna(u� ofe"x" 1617 Mail Siri'ice Centcr,.H:rleightNC.2 76 99-16 17
11.Horebolc di2tmctci;10" (in.) 24b.For LoliTgoa We%ONLY. Tn addirion to sending the folni to the address in
246 a6ave:A96 Submit a.copy.Of this fonn within 3(1 Am s-of coMpleti0n of well
12.Well coDstmetion.method: Sonic crotrstdarctioii to dtx followine:
(i.e.sugcr..ruaary;;sbte,dinci push etc.) Division of Water Readu rcesi Undergl ountl lnji etictn Control Pingranl,
FOR W R WATER SUPPLY j636bfnil$ervice'Ccuter.Raleigh,1727699-1636
13ar 1`icld(dim) \lcthod�of test:
2de.For Water Supply&Injection Wells.,
Also Sub One copy of this fi rm within 30'days of completion of
134.1 isinfec ipn tape: __ 'Amount: svcll constinction to the cbamty hcalth'•depanmett or the coliior.n'hcre
constricted.
]?orni GSt'-1 Noit}t Carolina Mlianmeut.of ErMionncnr and Natural Resources-Division of R'afer Ftesotrcrs het fed Atigust M3
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