GW1-2022-06258_Well Construction - GW1_20220628

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WELL CONSTRUCTION RECORD Forhrsnwtt_+so•NLY:
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1.Wdl Contractor Information:
Scott Hunt, Jr FRO51 Ila I DMIRWrION
�VcltCor�tatteri+.Inc ft. ft.
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NC TvYetl CotttractorCcnificatiaoPiunbcr
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SAEDACCO Inc 0 fl. ft. 1" ,tlr. SCH-40 PVC
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FR0M TD I DUAMTER I THICIMIN3 INUTFAtAL
Well ConstructionPet tRlt#l: R. i tt hr
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3.Well Uw(chcd&well awlsF:I
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W$tet'Stiftpl,V V'Ct@: _ Roil TtYM ntALUFTF„R - 9.0'r-W: TnICKNM AIATURttU
CJAgriti^ultural 0MunicipaliPiMic 6 R. 1 t R. 1" in. .010 SCH-40 PVC
©Crcatitennal Meating/Cooling Supply) 1311esidemial Watzr ftp@g(single) R. fL 1O'
DindusariallConintetcial CiRcsWcatial:%taterSuppl),(shated) 1e cRatf7. ... : :-_ r.
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Non-Rater Supply Well:
M'ulonitorikq oRcaocery
injection Ycu: R. rt.
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q,4tptifer Storage ao(i RCCOV R' QSalinity Dirtier 4 R. 16 R. Sand #2
DAquifer Test I]$(ormx",ter Dr4im'.;
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❑Expzrimcmal Technic a• iSUbsidcncC CoMr.of
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❑Creot11en1i 1l(Closei!Loop.) ❑Tr:<ter �@ROb1 TOnS5cRtPrla�rr�for fita,fp�wttrrtxk ,i elrl
OGc rtltelmal(Fleatin.Coolittg Rewro) CR]$tc'r( laid undet t#31 Retuatis) ft. ft See Geologist's log
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4.Date Well(s.)Completed: 6/14/22 Well ID#TW-I n �
Sa.Well Locattun
Commercial Property ft. tt JUN 2
Faoility.tlumrNmre FactlttyM(if2ppiaable) R. { ft. s �-�
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3400 N. Elm St., Lumberton, NC, 28358 H. 0. ,�,• ;V
Ph}skal Addmss4 City.anti Zip fit.lit M1tA1tAliri,.;
Robeson Temp wellifor ground water sample.
C'.1ur11y 1:IttC1(S:�ttff�Uiri7 Nb.(:'Ih') � i
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311,Latitude and Longitude in degre iminutedseconds or dedro tl degreer, rr 1
(lfuita Ittdtd,urfi IaU7uq i,4 atrircl:at) CcrtifiraHt►Fr.
lk W �C9t.L J 6/18/2022
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6.h(are)the weII(9)1 rVerms ent or SlTemporat}' fir szgniny leis jv .1 irzrebt•errrifs rhr r!hr urllfs!„rrs'j,srrel�tr,.rrnrered Srs mtrrni rca"
tririi 1i•1 NC.iC r#;C.t'lfk]ur'1 ,t NC+tC mC.r),a9(}veil Carrutrt'rc;it+,r Stci:ra'uuls crtul tdxar,r
7.IS this a repair to an existing well,- OYes or MNq tarpt of$rEr r,xni;3lrils lz¢ n pttserrG`a0 rn ttc;strll nrritcrr,
' 1f slar's iaa npatlr.,(!J real k±rt,i,:a aril c°.ruxut7iyua ii{{arrau�iau cirilaxr»'crrrr5t rirarurs c+f iiie ((
rer�,rrem9ertr2P n�u rkx ee:tom or rya rAr+hrr ul tiles furar 23.Site diagrAt or additional%veil detall3:
You tuaN,use tli a back of this page to pwtide additionat yell site details or well
$.ltttnllser of Hrits rnnatruaed: 1 conutuctiondettik You Rtay also alladl additiattat pages if r x: saw.
For mulfipfe igecrlam or atm-viwer ray,p{c a+eds ONLY wWi Me&rMe coammedog.wva etm
st0ma var forte:. MUCTIONS
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9.Total tF'e@I depth be$otr land dllrfa,:e 16 Eft.) 21a Far All Vells: Sabntit Utis form ttitlurt 30 d t)'s of completion of well
Firma ft.r:Ir iudh linnilder n ljril i`rrris(cxrrentri�•;rr�Zt71J'u u120-14W) COM metion to h tononiar;
iR.Static water level below top of cash.: A) Dili Eshm of Water Rciounres,information Processing Unit,
ff wryer leFrl is rrlrnve r'dt61 as,r 1017 Mail Service Center,RatciA ETC 27699-1617
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11.Borehole diameter 2.25. (irI) 24b6 a r t v ONLY: lit addition to sending tale feirn to the address in
24aabove.alsol submit a copy of this form within tti days of completion of ttell
12,Well construction method:DPT ccn seruction to gate following,
tte.nuger roar y,,anblc dimsl T%sh ctc;t
Division a Water Resource's,tTndetgt'ounti injection Control Prot,n`am,
FOR IMATER SUPPLY WELLS ONLY: 1036 Mall Service Centern,Raleigh,NC 376944636
13a.titdd tgptn) Nfeghod of SIG For Watce Suepiy&injection Wet1s
Also submit o4z copy of tltis formvvidiin 10 daysofcompletionof
t311.Duiinfectina ixpt"µ Amount: .
«ell consoucti n to fire courtly hColth'dcpammrr,t of the count*w krc
£t8n5it11CtCd, �
Fortu MM-t Nnnh enmItria M'Parlmcnr of£nriroatmin and N1MnJ Rewa e -Vivision of Water Relb rot Itevised:'1ugukM[' k
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