GW1-2022-09194_Well Construction - GW1_20220930

WELL CONs,rRUCTION RECORD For ltttentalUwONLY:
This fonncan tic used for single or nudlipk wells
1.Well Contractor Information:
li.WATER ZONES
Zach Thompson FROM I orm-supl-mix
%Veil 011Yf cu'r Name
4478A
NC%Nell ComralcnorCenifrcaiion Nontet 15.OUTER CASiiG'(for mtilU<auT1F 05)O a MkH ATf R1AtFROM To .8 LNL
SAEDACCO Inc 0 II- 581 ft. 26 in. I Sch-40 PVC
Comr.11nName 161NVER CASING OR7YIBIN(;`I mliferrfiaid6sed„4m,
FROM T6 pt411FTER I Tfll('K\F.SS MATF.RL�6
2.Well Construction Permit>:: t►. p. i,►.
Lim,dlzlyrlicnllr w '1 p nri;>(i"r.Count:',.Burt-,biuitrrtc�,i7�ECD[It ch:1
ft. ff.
3.Wdl lse(cheek well use): 17.SC,RE£N
Water Supply Well FR(►N I TO DI.4+IFTER MOTS17W I TntCK.%F-_%t: I MATERIAL
OAgiiculturd 0municipal"Public 58- tt. 781 A. 2° in. .010 1 Sch-40 PVC
I:ICieotheml d(Healikr"C'ooling Suppk•) 011csidcntial Water Snpptc(single) p. fa in. J
t:)IndustriaUConunercial I'll Reside nti:ll Water Supph isl►Imd) 10.FR NROUT. TO MATF.111,41. I F.d1P1lU ME\T MFTI1011 al AMOUNT 11
❑hti ytiou 0 ft. 54, (L Portland CemPntection
I
Now water Supply Well: n, ft.
®htonirorinr ORnotrn•
inJect on Nell: h. ft.
OAquifcr Recharge OGrmind tmicr Rcowdiahon 19.SANDK:RAVEL PACK(if�dical►It
►ROM TO SIATf;Rt41. FNIPI ACUNI►.VT Nf:T11Ow
OAgnifcrStor,►FcatdReemrn' OSaliniq l3arricr 561 8, 1 78, t1. Filtered Sand #2
OAquifer Test OStomntatcr Dminagc
ft. I ft.
0E\prrimcntal Technology OSuhsidcocc Control
! :20.:DR11.W\C LOG(aitact+addifionalsbectsitncmcsen•
❑Cnothcruml(Closed Loop) ClTracrr I FROM To IOFSCItIPilO\i(abr,hardae ta.orrl'mtRfr aia avt,Ar.l
OGeothennal(Reatilg:cooliue Re1un►) OOthet(ex lain under 421 Remarks) ft. ft.
4.Date Well(s)Complettvl: 8-5-2022 Well1DI)XW-213
.Z7
Sa.Well Location: ff. ff. ',"a.' .'' - 's i.- .. '
Fasilit}.-Ylt% r;Vann Facilin IDk i.ifarpiranle) -P�20'"2"®
ft. f1.
293 NC-740 Badin, NC 28009 Stanly County, , Dwor OG "
Pit)sica)Address.Cit).and Zip 21.RICSIARKS
RBentonite seal from 541-561
Cuunh Puled ld ttfilumlina No-I NI f
Sb.i aitudc and Longitude in df mw%/minutcs/ccconda or decimal degrees: 22,(crtific odilun:
(itself Wd,otc buff ttt_k stdli.kat)
35.401735 N -80.119548 �/� 8/6/2022
S" . lure ofCrniC �4'c11 Coatt hlcl. Datc
6.Is(are)the wrll(s): MPermanent or OTemparury f1."signing thin lmm.1 lave)-crrfify thin the mrJltsl torts is4riel tur_rJ
nit 7ed in rwr'e.r;/tmrc
41,011115A ACAC 0 C.01tki ur 1 :1 A1C:'rtc(11C,±i"09 11'e•il Cmist-r1'tkrr stAIphl thS find 6,11 rl
7.1%this a repair to an esistinll,well: c 7Ves fir 1MNo .t r)et thi:rro-nnl his hrrtt(rerridr l m tM pyl!awns•-.
lfilis t_ca relkdr Tll rva Copan krlllomont;i•rn 1-tformalipn the r11111 re tf tltr
reluir wrrlr•F.1 wim ak Ari-pim or an the ht k a this ftRrn, 23.Site diagram or additional well details:
)?oil may use the back of this page to provide additional well site details or well
S.Number of»ells constructed: 1 collsimction details. You imy also attach additional pages if mexessaty'.
fir maltlple i-dre rhni♦or ni+-n•pntrr wp[4 tuffs ONLY wah the somteutrsrrnefirnt,ce:n rot.
snhmtit omr farm. SUBMITTAL Il\',STUCTiONS
9.Total well depth bcloti land surface- 78, (ff.) 24a. For All %Veil%: Submit this form within !n days of completion of well
Vor m"hiple 1-dff list atl-lPpthS ,020'and 20/0)1 construction to the folloting:
10.Static water level below top of casing: (D,) Division of Water Resources.Information Prucessing Unit.
if rates levee it ah,•-e melt-.,uk "+" 1617 Mail Service Center,Raleigh,Nt:2 7699-1617
11.Borehole diameter.4° (in.) 24h.For Infection Welk ONLY: to addition to sending the form to the addreu in
23a above. also subunit a copy of this form within 10 dais of completion of well
12.Well construction method:Air Rotary Construction to the following:
(i.e.auger.salary.cable.direct posh.etc.►
Division ofWater Resnurrrs.Underground Injection Control Ptrrgram,
FOR WATER SU'PPLV WELLS ONLY: 1636 Mall Service Center.Raleigh,3NC.27699.1636
13a.Vicki(gpm) Method of test: 24c.For Water Supph'K injection Wells:
Also submit one copy of this form within .10 daysofcomplelionof
13b.DlsinfoYKion type: . ,, ,. Anmunt _ _ ,w well cominlction to the county 1w:lth department of lite coin)•whole
consinicied
Fonu G1V-1 North Calohim MIKirinkut of Em itummm aunt Naumal Rcxntrees-Limiion of Maier Rmources ftc%,twd August 2011