GW1-2022-06288_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD \ For New)Use ONLY:.
This,foruican Lvowd for siogic or nluhiplc falls': " �0
1:Well Cnntrlcior lnfornlationc
,I4.AVATEl1ZONM..
Robert Miller I FROM I 'TO DFS('RIPt10\
1Qctl CtirGfiGiOr ianli7 ft: ft:
fl. it.
2675
NC\VcllContranorCcnificfiionNliuVcr IS'.OUTER-'CASING forinuhk—ate. nells)OR1 iNER ii=a"'lkable
FROM TO DIMIETFR. - THICKNESS \1ATTRIAtr.
SAEDACCO Inc 0 fl., 45 fl: 2" in. I SCH-40 PVC
C<uiKi:liq'Nami 16.INNER CASING OR I RING lwrlbermal ekiwd-164
FROM W TO DIA.\IFTER. -THICA\E. MATERIAL
2.Wrll(:onstluction.RciT;lil q; fl. ft. 'ta E�i
1-41 all Colinh:Stn ei l i'uiatiC4 Trfw6rn r1C..Y
3.WC!1111sc(check\i'cil ase),: I7cS(?R!!N' _
Water Supply FROM TO DIAMETER SLOTSt7X THICh1INS 1'AiATFRI L
45 ft: 60 ft. 2" io• .010 SCH-40 PVC
Llrlgri.^'ulturat- Ultiltinicip:111l klblic.
❑Geothertua1(tieatitietooling Supply) ®Residential 11'ater Supply (single). fr.: ft.
. in.
Oindustrial/Couuficrcial 1111csidchtial 11'aterSupply(shared)'; I"la.GRouT
FROM -TO NIATF.RIAL t F\1PG�CEAIE\TAfET1fOU C.\\COUNT
❑hri''nlilin_ 0 41. 41 ft. Portland/Bea°Znidte
Non-Water Supply Well: '
(I. ft.
Mhioniloring ORccot'cry .
Inject ion well:. ft•' n.
DAgnlfer Rcti6rge l]GroUr►dlinlcr RCnlCdfalipD 19:'SANDN:R(VEL PACK of a i�Iiciblr S
_ FR(IM. TO' •ALi7KH[�hI 6.AIPI.ACrAI NT MMIOD
❑Aq ifcrStorlgcand`Ritio\et}' ❑511iDih.H�TnC1. 43 ft.: 60 fl. Silica Sand 20/30
OAgmfcrTcst ❑Stomm tcrDrfinaac.
ft. ft.
OE�p^rimcnteLTctihnolo ❑Su6sideDcc CorArol
20;:111RILLING1OGfdtlactiadditionidalicNs`.i/nccciinnt ,.
❑rr2otheln al(Closed Loop) ❑Tracer, .FROA1' I.To DESCIIIPT10N(+ubr.herd"6+.udbiwk h x.^ibt ire.ter.)
❑G-oili<mul(AeadnetoolingReturn) ❑Other(ex laiininder9-l.Retnat-W 0 at:. 50 ft. 'Tan silt
50 :(1.:" 60 ft. PWR
4.D:ito'Well(s)Completed 6-6-2022 Wc1IiDNMW-1
It h:
5a.WiMUc4tion:
Wood Automotive A. ft: JUN `r
Faoilii)cOxn r�lanic Facility Ine.titappti able) fl. ft. �����In#iilT:u�tC l Pi_
. . . ­.WYe4:r3 Una
2020 Old US Hwy 601 , .Mt. .Airy, NC, 27030
Plnsi;uf>addrcss.'Cit}'.andZip '21:�REDIARKS-`, -
Surry 2' bentonite seal from 41-43
Ca roily Mirel 1J_utirtG7tibu No,(P.114)
5ti:L atitude a1ii1'.l on),dtn11C in dcgri•cs/lnintitcsLiccondc or decimaldcggccsi. 22:CclTificatibn:
pfpclf fall;ota)at76ug i.clihicifal �
_6/10/2022
Sigcntilr of�';t;, ;rj.�;=`:! '_4 rr::!' " Dafc
6.'is(are)the well(s):",XPennanent 'or" ..O 6iliornrv..
Br 37,1'n//le rw.I hereby e�i riiij-OaT OIL'Wellj.r j Irxrs{tern)tdnulisr rc°rl.ill ircror(M ce•
,OMY 1&I NC+iCO2C.01f](l iir':1SA A'4'rtC O?C ii7?(]p 11i+It Cnnirrsn.ritiil Srdrkfartl.'a unifrhr,T
7.1� htti.a repeirtD'au c istinjwcll: . ❑Vus 'tir ENl!'` i'ah>njrhis'r+cni fhni hrrii prcY+lrl il:iirihctilv;l mlilcr,
lJrhls rc a rF1rlNr,fi!!iarr iatririi 1+•e!1 ecru rlrcr7an NnjGrrrxriirnr and i+.i7rNGtn rhe,nnrnrc njrlm '
repair artk7B2i reomrkd:Ar licr.or[xt the brwkof dli:form. 23.-Site diagram or additional well details:
l`ua;in l):Ilse Ilse hack of this page-to'pro\7de ad itional lvell site details or.ri 11
8.Number'of Its.cotfstrifctcd: 1 ctinstfuction'itetails:'You'tio also attach additional.(h1,g'C8ifnecessfry'.
Fur.mnblpVr nfc'C7iDl1 Gf/ltNl-lfUit'r}7rrflrl lr+'!/i Oi�Z}'»'kh'thY�.snnrecmrstruefioil;�•G:ccr:rl - � ,
.ruf,mir ima fnrin. ,Sl1BMI'r rAL TNSTUCTIONC'
9.Total will [it !►eloa� Iand ulrfucec 60 (ft,)'. 2aa I n All )�`clls:.-,Subr lil dhis for i widun 3t1 day. of conlpletioti of.well
1'0r nrldlwe ii NU Nis,,a11 delnhs li dijl[re4i dexmiif,lc:,?,2tYY tuu1.2@ Ilk)) constiuclian to the following:<'
lll.Statie 1►atcr herd treloly top of casiu{;: (ft.) bir iafon of)Nails Rttiourct\;lnfnrma$on PnaccsSing Unit.
Ija'[inrr lev'el 6 above'cirsirt:N!4'"i" 1617 Mail Set-vice Ccntcr;Nalci(;fi;NC2769J-1617
11'.iiorelfoic diameter;6" "(in.) 24b.E 1 f Ishii We115 ONi 1': b►addition to sending t11e foul to the addrim in
24aaboV6. also submiC a wpr,of tbisfunu\\ldun.,30 days'of,C*O—In ctiou of:i%ill
1L.'Welfconsctruction method:Air Construction 16 tile tollolvirig:
(i.c:pager.rnisq:ieSblC diiecf putt cica
- ;I)h ision of.�Vater:Rcsour�cs;Uoder°groun.d. cciion Control:Pm;,rram. .
FOR WATER SUPPLY WELLS ONLY; 163fr iifail Scrt'ice'Cenler.Ralel.gli;\C27699-163(o
13a )rcltl(}ry►m) bicttit.d of test:
�1c._Fnr Water Sunni\'&inlirlitrn\Vc115:
Also submit one copy`of tills fomi 1►ithiti .U.daysofconfpletfolk0
13h Ulsinfitinun type., _ _.. - Amount:.
\yell constntctioli(o.thc.cminq•'health dcplrtnlcm Of.tbC co1IlIIv' `Ifcrc
constnlcted.
Fonn G\1',I Nonh Carolina Ucp?nnxnt of Eneirounxin andNatltral Resources-Division of waterReso1rc(s Revised Atiuq-_tiI`.1.