GW1-2022-07922_Well Construction - GW1_20220823

WALL CONSTRUCTION RECORD For lrtcnmlUscON1.l':
This firncan be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZON►S
Stefan Smith FROM TO 0F5(,'RIP"ON
Well Cortrrctor Namff. fl.
A. n.
3576A
NC Well Coniriclor Cenifecation Number 15•`OUTeR CASING for:muhleasedwills)OR LINFR if:e ikabk `
FROM TO fit-+ FTER TIItCKNESS I MATERIAL.
SAEDACCO Inc ft. ft. in,
G0111F.—bl Name 16. N rNFR CASING IN;OTUBG eoiberroal cki►rddi oo�o =.
ER I THICKNESS M.ITERIAL
2.Wctl Construction Pcrmit K: 0 A. 15 ft. 2 m• 40 PVC
Li+t irll applirable,If p nnitr 0-r.Cowin•.Shar,I"nriarwir.74er6 r1 etr.l ---�
ft, ft. in.
3.Well Use(ch"k well use): 17.St
.
Water Supply Well: FROM I TO I DIAMETER I SiOTSIrr, I Tlr(T<NFS$ 'JIATP.RIAt:
L1Agricaltural i�MnnicipaltPublic 15 A. 25 ft. 2 in: O10 40 PVC
OGeothcmpl(Hewing,'Cooling Supply) OResidentiaal Wmer Supply(single)
Obidustrial/Conmiercial OResidemial Water Supply,(shared) 18 GROUT'
FROM I TO MATF,RIAL E%tP1ACT:MitiT 3lrMOU&AAIOIINT
Dirrigation 0 ft. 11 fl. Portland Pour
Non-Water Supply Well: A. A.
IlMonitorinq ORccovcn'
injection Well: A. ft.
❑Aquifcr"Recharge (30ound+s:itcrRcntcdiaiion 19 SANDICRAVEL PAC K(if ilicable
FROM 7ri D1ATY.Rta1, 6:MPLat'tytENTMI:Tn011
❑Aquifer Storage and Recover' OSalinity Harricr 13 A. 25 ft. Sand 2
❑Aquifer Test OStornnvatcrDriinage ft q
OFylerimcntal Tcchnoloa ❑Subsidence Control
20.DRILLING-LOG-fattach'additional sbeets if nee6 su'-"
❑Ge(ltheniial(Closed Loop) OTmeer FROM TO DFSCRtpTIUN Notir tiaretncc rdVn,ckYt a SfuC Hc.l
OGeothemral(Reatinatooline Return) []Other(e% lain under#21 Remarks) 0 ft. 10 it. Fill
10 ft. 25 ff. Rock n,F
4.Date Well(s)Completed: 15 July 20nel)iD#MW7
Sa Well G►eath)n: ft. ft. r
Power Secure ft. ft. y
Faclity,'Osvrct Namc Facility,WX(if applicable) ft. ft
1410 Coltrane Mill Rd. Randleman, NC 27317 Randolp, ft. ft.
Randleman, NC, 27317 Plrcsiatl Addmss.Citv.and Zip 2L RENIARK.0
Randolph 2 foot bentonite seal from 11 to 13 feet.
Ctmtil1• Parcel Id-:alific-tlion N(. (PiN j
Sh.Latitude and Longitudc in degrecslminutesAcconds or decimal degrees: 22.Certification-
(it
vell field,ore Wiloq is s,fiicwM)
35.910997 N 79.852044 W 7/21/2022
Sigrot: of Ccfi d VJc11 Contr�.torm - �SY Date
6.Is(are)the well(s): `2)Permancut or OTemporary fir signing this fitim,l herehi e'rrtife rhat thr nxllfs)tms fworr)iv..nc+nrrtrd hr aot•ordrmce
with 1 SA NCAC 02C AM)or ISA NOIC 02C.0200 Well Consirta rinn Stanta+ils oral thn+n
7.Is this a repair to An exhmng well: Oyes for Z No copy nj'rhr`s rrrnnl has horn pmrfdrof rit)hr stvll au•ner,
if thls is a fe)aair,fill rw Pnouvr Ivetl redolourfinn btformarlon rind exPlahr the narare of the
repair under 021 or rm thr hewk of this farm. 23.Site diagram or additional well details:
You may use file back of this page to pro%ide additional well site details or%cell
S.Number of wells constricted: 1 construction deiai is. You'may also attach additional pages if ime-essery.
For tnarhiple Jollecrion fir ofol-wafer s,rppl•e wells 01f'f.1,w1rh the some eonsrraeliwr,you corn
subuutonr fnm. SUBMITTAL fM UC-TIONS
9.Total well depth below land surface: 25 (,ft.) 24% For All Wells:. Subnul this form within 30 days of completion of%veil
For nwhiplr n'elis list fill dernln ffdifferent lexrr»,pte•86-200'mui 2e IM) constniction to the following:
10.Static water level below top of casing;: (ft.) Division of Water Resources,Information Processing Unit.
lfnrte+letr!J;ahure ensinX.+far"+" 1617'Mail Scrvicc C:cntcr.Raleigh,NC 27699-1617
i
11.Borehole diameter.6 (in.) 24b.For luk%lion Wells ONLY: 'lit addition to sending the form to the address in
24a above, also submit a copy of this fonn within 3q days of completion of well
12.Well construction method: HSA/Air Construction to the following.
(i.c.anger.rotaq•.cable,dims push etc.)
Division of Water Rcsourccs,'Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen'ice!,Center.Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test. 24c.For Water Supply&injectiotn Wells:
Also submit one cop)' of this form %viihin 10 daysofcompletionof
136a Disinfection type: __ _ _ _ Amount: %yell construction to the county hcidth department of the county w hate
constructed.
Forin GAV-1 North Carolim M-Wrli raw of Ent irDwmmi and Naitual Resources-Division of Waite Reno rcm Revised August 2013