GW1-2022-07960_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD For lmcrna1Usc0NtY:
Ibis form can b:awd For single er rnwripk antis
1.Wd.1 Contractor fidormation:
.14.141ATRIMONIS
Zach Thompson FROM TO I o"Cla"10K
UW Contructot Nam R. ft,
4478A R. ft.
NCWcJlCan=ctorCertifimionNu.mbes 15.0trm I ING LUJIMEMR(Iff- Nca1lki.
FROM TO PTAbtEFER TBICIMM MAMIAL
SAEDACCO Inc 0 ft, 50 ft. 16" 4 in. SCH-40 PVC
caloplAy NOOK cl6wd4o6p)
FROM Ira DtWOMETMER THICKNESS MATERIAL
2.Wdl Construction Permit R. ft 6L
U&#fl amikylble wwll penwits(F-r.cmrar ft,
fit, in
3.Well UK(Chmic well use), 11SCREEN
Water Supply Well- 040 TO DMAMTER SWT SIM A 114100M I MAVRRIA1,
MAgricultural DAInicipalTublic 50 ft, 110 ft. 6 in. NA NA Open Hole
®Geothermal(healing Cooling Supply) ®Residential Water Supply(single) It. R.
Erg
Cludastrial/Corturercial 131kesidenfial Water Supply(sbared)
FROM 10 MATERIAL -EmPlACEWEM ME OD a AMOUNT
ohliga{ion 0 ft, 50 ft. Portland Ca mAntection
lion:Water Supply Well; fL ric
..;®MonitoringpRacatr
Injection Well; k R.
QAqui(crAcchargc E343roupdwatct Rcotc4iation l4 SAND RAVEL,-PACE
QAqoMr S", c and R=oiriy 08alinity l3wricr ft.
0 Aquifer Test 0sto-1111% tcr DrainaVc
DIEVC[imcph,Urcchnolozy 0subsidm- ccontTol
Meodiermal(Closed Loop} Mracer
FROM TO DESCRIM01%,0*10r.Ihmedne".ww"Ick lypt.owl!*&tkJ
Meollmmal(ReatftLP&zoli!1 Return) 0 (L so ft. Brown silty sand
00ther Leim�ia under#21 Retnaft)
50 ft, 110 ft Bedrock
4.Date Weff(s)Completed: 7-28-22 _We11ED#MW-5 R
R. (L
54,WC11 LAIC91111M.' fL (L I
w -:0 2@22
Riverview Grocery fL to.
4� ;MQ­:u= I Ir
Facffity)M�wrNnm Facilih I n n r21r
-IDN(ifopplicab1c) k rc DpVQGOG
8270 US Hwy 321, Sugar Grove, NC, 28679
Address.City.and Zip
21,REMAX"
Watauga Open Borehole from 501-110,
Co"My Parcel Idesififtc0on No,(PIN)
5b.latitude and Longitudc in dcgrccstmJinutWkc6nds or decimal degrecr. 22.Ccrtirkafion:
(Itvio1l field,one IMAoiS is smil3c4otd)
le
36.267364 K -81.885668 —W J?��-/;T9 7/29/2022
WNMM.7 tar Daft
6.Is(am)the wcfl(a): 01permancul or MTemporary By riming Mit firm,I twrrbt,rerfih-dear the it-tAfs)way(wwrj cwnrinrezed k7,wtvrdAnre
,;Xt M NCAC 02C.01M or-154 Mc4c 02C.02VO Well comfMcdoit Standards and 001 a
7.Is this a repair to in exi.0mg well; Mes or Moo copy of(1117 rffoo 1wx bemp.mildm ra Jhc MrIl finuter.
If This Is a repdr,fill ow bmm uvft commfafan brfamuttion md expfahi rlje;k?rmre 0frije
reMirwrderP_*J rmagisserfim aron the 23.Site diagram or additional will details:
You may use(he back of this page to provide additional wall site details or well
8.Number of wells conaructed: 1 constmetian delails. You may also attach additional pages if necessary.
Fo r i itafriple 1ttW;-km or n tw i-4wer mVply wells ONLY ii irA the mine;;ww—-CAP".year Can
xUbmuir one farm.
IMIUCTEONS,
9.Total well depth below land surface: 110 24s. For All Wclln- Submit this rout uilhin.10 days of oomplelion of well
For)"MMple wells lilt 47114fepft Jfdolerew(exatxpre-3@2M,and 2@ f(W) con5intedon to the following;
10.Static water level below top of"siuq-, N/A Division of Water Re-4ou rcM Information Processing Unit,
Ifuum,1evq As above castfiR,MM"+ 1617 Mail Service Itentcr..Raleigh.NC 27691-1617
r
11.Burchak diameter 6 OIL) 24b.&C JpWWg0 FjlLq ONLY: In addition to sending the fom to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well construction method.Air Rotary mnstmetion to the following.
(Le.sugar.ri%uv,cable,dirm posh etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Cenim Raleigh.NC 276"-1636
1
I Ia.Yield(Ann) Method of test Ur—For Water Sun ely&1RjcctkinWctb;:
Also submit one copy of this fainil within 30 days of completion of
13b.Disinfection type- Amount: -.vell const"Icrion to the County"Calth dqmnmczu of the cmuly whm
coagnictod,
FarmGW-t North Carolina Dcpanami ofEmumnacni and Nartiral Resoumes—Division ofWater"Resourom Rcs,iscd August 2013