GW1-2022-08692_Well Construction - GW1_20220519

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple welis
1.Well Contractor information:
Bill J. Payne Jr.
Y Y rR031 TO DFSCREPTIO?Q
Well Contractor Name 12 r" 22 ft• non-potable water
4532-B ft. ft.
NC Well Contractor Certification.Number
15:OUTER'CASiNG.((6'ii ulti�ised;►seIDs ORLiNER.ifu blicuble
FROM TO DIAMETER TttICiC\tESS MATERIAL
Civil& Environmental Associates, PLLC fL ft. in.
Company Name 7G.TPt DER CASING U117 UBING t)thi anal ctasrtil lao
12895 FROM TO DIAMETER TtIICI MESS NIATMA
2.We11 Construction Permit#: 0 ft. 8 it. is
List all applicable rrell pernuts(i_e.County.Slate.Variance,injection,etc.)
3.Well Use(check well use): 17tSCREEN
Water Supply Weil: FROM To DIAMM11 SLOT SIZE I TInCK-ESS I MATERIAL
[]Agricultural QMunicipaUPublic 8 fL 22 f6 2 in. 0.10 PVC
OGcothermal(Hsatn Coolin Supply) []Residential Water Supply(sinSIc) fL fr' in.
18;CROL)T _.
QlndustriaUCommercial QResidential Water Supply(shams FROM io r MATERIAL SVIP 1tE7HOD S_11110IfNf
Oirrigation 0 fr. 6 ft. bentonite/ce tremmie tool for cement only
Non-Water Supply Well: fr
OMonitoring []Recovery
Injection Well: fL ft.
OAquiferRecharge OGromidwaterRemediation 19.SANDIGRAVEL'PACK(ifa hcablc .-.
TO NIATERLIL EJIPLACEMENTDIETHOD
❑Aquifer Storage and Recovery QSalinity Barrier FR0;1t
[]Aquifer Test OStormaatet Drainage 6 fL 22 ft. sand
fr. ft.
OExperitnental Technology ❑Subsidence Control20.DRtLLLNG LOG(attach additional streets If tieeessa
OGeothermal(Closed Loop) []Tracer FRo.1I ro DESCRIPTION(color,hardness,soWmek type,grain On,etc.)
OGeothermal(Heating/Cooling Return) []Other(explain under 021 Remarks) 0 ft. 1 ft. Reddish brown silty clay
4.Date'%Veri(s)Completed: Well Ill#
4-4-2022 MW-6 2 ft. 15 ft' Tan silty clay
15 fr. 22 ft• p;=Yellovi(,sll�j/cl3y�
Sa.Well Location: rt. ft. e.
(former)Space Dye Plant it ft. MAY 19r)
Facility/Owtter Name Facility TDN(if applicable)
ft. ft.
101 Main Street, McAdenville North Carolina 28101
Ph)yical Address,City,and Zip r , .e „n- r��• t:;1
';:21REt1L4RKS cr�7!,, �+oy caner+ )r✓•rcas+,v r r rn-. +
Gaston PIN#3585063142 0-8-ft casing
County Parcel Identification No.(PIN)
5b.Latitude Ad Longitude in degrees/minutes/seconds or decimal degrees: Cer' atiolt:
(ifwell field,one lat/long is sufficient)
35.261136 N -80.077218 �v , — 5/3/2021
Siang enificd Well Co tractor Date
6.Is(are)the well(s): ©Permanent or QTemporary 13y signing this form,I hereby certify that the vwll(r)ems(were)cilmtructed in accordance
with 15ANCAC 02C.0100 or 1541VCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an eszsting well: []Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out knom well construction information and explain the nature of the
repair under#f21 remarks secuian or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to protiide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Formttlaple injection oraon-wate•sttpph•wells ONLY W Will the same consi ruction,you can
submit anefonrc SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: MW6@22r (rt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For audliple wells list all depths if different(erantple-3(VOO'send 2@100) construction to the following:
10.Static water level below top of casing: 12' (ft.) Division of Water Resources,Information Processing Unit,
If,rater level is abore casing,use•'+" 1617 Matz Service Center,Raleigh,NC 276994617
11.Borehole diameter. 4 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
auger 24a above, also submit a copy of this form within 30 days of completion of well
aU
12.Well construction method: g construction to the following:
(i.e.anger,rotary,cable,direct push,etc)
Division of Rater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed