GW1-2022-09189_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD For lr+tcntal13wONLY:
This f0mcan toz used for single or nndfipk wdls
1.Well Contractor information:
Ii.NATER ZONES
Zach Thompson t FROM I it) aFscutPlT<)�
Well Comm am Name
4478A
NC Well ConnactorCenification Netitl ei 15.OUTER CASING(for "0s OR LUYER'H'a IRable
FROM TO Dt•\>tETF.R Titlt F�TSS MATERI.A1..
SAEDACCO Inc } 0 ft. 24.5' ft. 21 io. Sch-40 PVC
Coutfr:myNalm 16.INVERCASINGOR;It BIND eollterinalcloud•lory/
FROM T6 DIAMFTER ffi1CKNFSS MATERL�L
2.Well Construction Permit q:
List aRrl)Wi+_'abb•wr11prnritr0,c.Common,S:+rte.1ariatrer./!Mond+:}
ft. ft. in.
3.Well Use(cheirk well use): I7.tit;R)k EN
Water Supply%yell• FROM I 'TO DIAMETER S1.0T IT3' t1i1CK\I\% I s1ATER1 1.
l7Agrictlhural t 1Tvfonicipd:T'teblic 24.56. 29.541. 2° io• .010 Sch-40 PVC
0Geothentud(Neafin);/Coolin£Supply) 01tesidcntial Water Supply(single) � n. IL in.
taindustriaUConunercial isJRecidcmial Water Suppl•tsllared) 18.GROUT 1
FROM 10 MATERIAL EMPLACEMENT MET1tOD&AMOUNT
Clirtilsition 0 it. 20.5' ft. Portland Ceirmtection
Non-Watter Supply Well: 1
n. rf.
MMonitnrin-, ORccoi cn
injection Well:
QAquifi:r Rcclixge QGmnn duntcr Rcnucdiation 1 19.SANDICRAVEL PACK 6f 4kable
FROM 10 MATCRIAI. NMPIAI;F.MEVT Mrmit n
QAquifcr Stomgc and RanvEn' QSaliniR'Barrier 22.5'ff, 1 29.5' A. Filtered Sand #2
QAquifcrTcst QStomncatcrlhailnagc
❑Experimcntal Technology QSuhsidcocc Coniml
ACT
LOG(aifach additional sbWs if akesmim-
0Geothentu l(Closed Loop) ❑Tracer t FROM To I D1 ticRrPnoN iY»►ir.hllydn.�a,Wa'r,°1,a .;° n..aa
❑Geothemial(Heatint-Cooling Return) ❑Other(eY lain order 021 Rentarl s) 0 ft. 1 21' ft. Brown silty sand
21' ft. 29.5' t1. l Weathered Rock
a.Date Wellm Completed: 8-3-2022 We111DAMft-211 tL R. ,
5a.Well Location: ft. ft.
Alcoa a. rL Facile$:+Ylttnr Name Faetli» IT)� ppli tifa ::tble) --•-•�-- -^c---•�-•- -SF P �`'"•'�-mQ_292Z _�F
fl.• tl.
293 NC-740 Sadin, NC 28009 Stanly County, B• ft• .Y .+e•. UMi
Ph%sivil.address,Cit}.and Zip 21.REMARKS
IBentonite seal from 20.5'-22.5'
(`outac PareClldcalife�AiuoNo.tPl�t
5h.Latitude and I onEitude in d(recsin inuteslsccands or decimal dmrce. 22.Certification:
(u-ucll field,nm 1all11u is ctrlli i tl)
35.404729 N -80.121931 p' N 8/6/2022
51'cTslctr.ofCcnif P cil Coanrtstof "i Oasc
6.Is(are)the%Tell(s): EPentnuient or oTemliorary lie aignitlt 064 farm.I hr'rrhr crriih:fhrtt the ur/1tx1 wmi iwerri r,mvi/mred in f-ce&dtmrc
WW1 14,1?%,CAC 0 C AHVi or 1 A NC(C 0dC fiI(3!)11,67 Cmn mtrr,on Sr+,,kiwab«11,I tl+.n,+
7.1%this a repair to an existent:well: JYes or EN/1 s nt r11i:rr,i re!h.r.>'j.•.vJ lJt+srirl o:to rh+ sn-!!m Jt.•r.
ljthi�ter'R1uUr,f11 i r (l r,x7r 1.+11 c'mri'rtJ Y1,�N hrfr+ntMfi(n+tn+d+s(+lour r1u'tu:tatr!�1 the
mutate undrr 021 remark.,a-i-tim at cm the bt k of 111i.,firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 cwlstnrction details. You may also attach additional txages if irevessaty.
F'c,r mvbr'rv4 i,:frrrh�1 of rt%q1-s+'n::v 3t+p1r!s s!':•11S D:�Y,t't+rth glee xtmecatrsrracli+Hr,c,::J rt+rr
.srtbour ixir f,r- SUBMITTAL INSTUMONS
9.Total well depth below land surfacr. 29.51 (n,j 24a. For All Wells: Subutil this form within 10 dams of completion of wcll
Fm•rnatlliple uvlh het tell lepyhc "IQ INY1 conslnrGlon 1D(he fhllowing
14).Static water level below top of casing: (it.) Division of Wetly Rekourres,Information Pruccssing Unit.
if rrarry tenet is 1t1+(!s•r r'lutn„rt_k "i" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter..8° (in.) 22h.FOE InjI;ion Will-ONLY: to addition to sending(fie fort to the address in
24a above. also submit a copy of this form within 30 days of completion of n•ell
12.%fell construction method: BSA coustnlciiiln to the following_
(i.c.auger.rolan.cable.direct post:ctc.t
Division of Water Rcsourecc,Underground injection Control Pfr►#;rinr,
FOR WATER Str'PPLY WELLS OINLY: 1636 Mail Service Center.Raleigh,;NC 276"4636
13:L Yield(gpm) Method of test• 24c.For Water Supply&Inicxtion Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: wcll construction to the county health dcpannirm of the county wlicir
constructed
Form(IjW-1 Nonti Carolina Dfarimcm of Ern monincnt ami Namral Resources-Dn uhm of Water Rmotrres Rc%ised August 210 1 i