GW1-2022-06963_Well Construction - GW1_20220722

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WELL CONsTRUC'CION RECORD 1
Far I,¢crnn111sv ONI:l':
Mi form can beuscd for singleor nudtipk twlls
1.Well Contractor Tnformallon:
:. L WATERZONIS ,
Stefan Smith FROM TO D"ClItMON
WdlCar ractarNamc 26.4 R. 33 R. Groundwater
3576 (L fl.
NCWcilCatmnctarCenifwcitionNwuber iS OUTERCASfNG f6i iautil-ras,iiiUs O R=LINERrifa"fJcabk'
FROM TO DTA6IF,TER TIIiCLLVESS \1ATEniAL
SAEDACCO Inc 0 (L 1 23 ft. 2" I lin. SCH=40. I PVC
Conquuty Name l6 INNER CASING OR TUBING` walbermA clusxdaoo
FROM I TO I DE MISTER I THICKNESS I NAURUL
2.Wcll Coustructi0tt,pglmtit tt: t(M0301210; 70003022 R. 1 ft,
un uilapplica6le'-ell pel-ki 0 C.Caunht'Shop,Variawe.Lya'0cn eh:J
R.
3.Well Ilse(check well use), 17:SCREEN
Water Supply Welk FROM TO DIAMETER S-LOTSUZ Till NMS I AIATERIAT,
ClAgricultural ClhfulkicipaMblie 23 ft. 33 R. 2" ink 010 SCH-40 PVC
®Geothermal(ReatingllCooliog Supply) ®Residential Water Supply(Single) fL fL Iry
l3bidusuiaWonmiercial Mcsiaendai Water Supp$'(shred) M GROUT. .„ ,
FROST TO " JIATERUL EMPLACESII3VT MSInOD S AMOUNT
❑1[ri tiP» fL (L
Non:WaterSupply Well: R. tL l
®Monitoring pRccovcy
In)eclion Welk. ft. ft.
13At)uMi-Rech0p Wtornido:ttcrRcutcdiation A9:SAN1D1GIt;1ivE1;11ACX(ifaj flGcahrc):^
'FROST 10 STATIMAI. RNIPLAMNUNT NIM10i1.
C3Agaifcr-Stocagc andRcco�'cry' 17S.alinity 13ariicr 21 ft.. 33 ft, Sand'#2 Pour
❑AquMi-Test Mlonmmatcr bn,L'kupft. fi:
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❑ xpetimcot ti Ttchnotog} EISubsidcncc Con4rot
120 DRILLINiGJLQG`!attachaddMoudfikvf ifucccsmry1
❑Geuthenud(Closed Lanni ❑TT..icer :Moll I TO dal
❑Geolliemial(Healing/Cooling Return) 130ther(c`zplainunder 921 RewatksU 0 fL 0.5 R, Gravel
0.5 fL. 3 (L Clayey Silt
4.Date WcU(s)Cawpletcd: 6-8-2022 Wvgl jD#TMw-7 3 f4" 10.5 R Silt
%
Sa.Well Uptinin 10.5 fa 33 (L Sandy Silt
NRP Holdings, LLC N/A (L fL JUL
�J I 2 9,
Fscilii},QuticrNotnc Fic0ity iUV #piicabJcl R. ft. ` f+
.3934 Raleigh St., Charlotte, NC, 28206 ft. ft.
Plrysicul rlddrass Cir}•-And Zip 72.L.REMARKS'
Mecklenburg 09107202 3 foot bentonite seal from 18 to 21"feet
Cctanl} Mrcd Idoilif=tJon No,(PIN)
56..I.,atitiide'alid 1;ougittrde in degr'ceslminutesAeeands or'dccinul dcgtees: 22:Certification: II
(iftLn rie►,l;�,�Jatrlo6i;is snnteiaw)
35.150829642 I~i 80.474946611 �V _ 7/l/2022
Sig�c.t-ued V7,IC Connector Dale
6.Is(are)the.rvell(y): UPermanent or .ZTemporni'y �'
By signing thir.farm,1 hereby irrrijrt dart-the n•elt(rJ erns•(Miein)curss7nrerrd in,"Qiror5ldarr
ideli M iVC+IC 02C,0100 or ISA aYCite.'o2C,020V Prell Coirsrrrierfon Srauda4s w d Akita
7.16.this a rcliairfu a�gdsting-Well.- ❑YeN or ENo COY ff r wAl hos been nrovieNI ro+;br irli murcr.
0hfsls a repalrt fill oar krii+irn uadl rnruynrcrfvi,btfanna8wr mul er(ifab,the+unroe ojihr I
repair amler A31 recnurkrsreti.ac.the b.1-•of;A&fame. 23.Site diagram or additional well details:
You'(Pay use the back of this page to provide additional well site details or well
S.Nptuberof wells coastmera: 1 cottstittcdorcdeiai[s. You ma}•";attachadditiauaipages if necessary.
For)ual(lpfelojecM?norn(xi-pnrersopid arilsO,YbYn•irlidiesameco,rstrur(lar,yol+caPd
sadwirane femi SUB111lTTAL INS'PITC'fit7N8
0.Totalivdldelkh below landsurfacc 33 ((1,) 24a. liar All Welie: Siibinit this form wi(hin'30 days of eompletiou of well
For nniulpfuweui`ifstmideptin1fdaerent(erampte-3@20A'mxl2@IM7 eonstniotionto the fottoniug;
10.Statie water level below top of casing: 26.4 A) Division of Water Resource_,!,Information Processing Unit,
ijnx,ler level Is above eudae;are"+" 1617 Mail Service 1- Raleigh,NC 2769 9-1 6 17
It.Borehole diameter:S.25" (in,) 24b.F it on Wetic ONLY` in addition to sending the fomi to the address in
24aabove.also submit a copy of this form within 30 days-Of completion of well
12.Well constmetion Rlethod:HSA construction to the folloMng:
(Le.augur.-ra19ty.cab1F dinxt Fusk ctc j
Division of Water Resource,Undergronud IIr]eclion Control Program,
1636 Mall Service Ceirler,Raleigh,NC 27699-1636
FOR WATER SUPPLY\VBLES Q}bII.Ir: � (' ,
13a.1 Weld(glint) Mabod`of test: ''-ze For Water SuDnl_r&Inlcctttin Wcliv:
Also subiivt one copy of this fnnti within 30.days of completion of
13h.Disinfection type:__ Amount:, well construction to the county' Ith department of the courlh•whoa
eonsiinctcd.
Form G�V-1 Ronh Carolina flepa,tmcar of Eovironmcnr and:InPws1 Rcnswccs-Dit i;lan of�Va1cr:ReSau Rcv1scd August 2UI:i
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