GW1-2022-10366_Well Construction - GW1_20221115

WELL CONSTRUCHON RECORD For lrtcmdTQrscONLY:
. This Form can be used fm single or multiple wells
1.W4Contracto r Information:
W.AVATERZONK&
Zach Thompson FRONT I To Dricittmox
W01Cor4radorNam R. ft.
4478A
ft. I ft.
NC Well Carmacjor Ceti ifrxationNumber �t&OUTER CASING((or:iuufti c:b€edf�icllsl`QR LINER(if."a'`17ca6rc
FROM To DMInETER THIC[�NESS NTATERTAL
SAEDACCO Inc 0 (L 35' (L 4" in. Schedule OPVC
Coinpanj•Nani 1&'INNER CASING OR' BING`' roikrmal clowdaan
FRONT TO DWIFTER THICKNESS MATETUAL
2.Well Construction Permit t ft, ft, 6a
Liar ill applirabl r WellpC12WIX Lcr..Carnry,Strttr,lrnrinrwr,11facuat efr..J (t
3.Well Use(chccic well use):
Water Supply Weil: FRONT I TO WANtF..TFIt I SLOTS17B I T1LrCKNrS5 NIATRRTAT.
DAgricuitural riNfmicipalftblie 35' It. 1551 ft. 4" in 020 Schedule OPVC
®Geothermal(Heafing,'Cooling Supply) ®Residential Water Supply(single) ft. %
01ndustrial(conmmclrial ®Residential Water Supply(shared) S.-GROUT
FROM TO MA1VM%L I ENWL M.MNT 3MMOD&AMOUNT
❑irrr ation 0 @. 27' It. Portland C fection
Hon-Water Supply W all:
mhlonitoring QRcco),T:ry rt
Injection Welt:
0Aqu*rRcctrttrge ❑Groundli-mcrRcwcdialion 19 SANDlGkA1VEL PACK fif ilienhre)
FHOv. TtI N1ATPRLO, RNIPL kM—IV,14TMET"On•
ClAgoifcrStormgc and R=ovciy ❑Salinityl3airicr 32' ft. 1 155' ft. Filtered Sand #3
❑Aquifcr Tcst ❑Storrawatcr ihacn,91;c
❑l=xperimcnfai Technology ❑Suhsidcricc Control
20 DRILlll1&i`LOG tnnach'addiliotnal'sheelsif necccsmn•
❑Geotltennal(Closed Loop) ❑Tracer FRONT TO OFSCRLPTTO\csfbnManlneM wR'nrcKhx, n mrru<Iri
❑Gmdlennal(IieatinelCooBn2 Return) ❑0111er(plain under#21 Remarks) o ft. 1.51 f4 Top soil/ clay
1.5' ft. 40' ft. Brown Clay and Mine Tailings
4.DateVYe11(9)1l7omple1ed: 10-17-2022WdIID#RTKM 22-403 40' ft. 155' (L Gray Rock?-t,r->w
5o,Well L oc rtion: (L ft, �"' V
r Ll
Albemarle ft. A. NOV
FactlitpUivacrNtow Facility IDR(fopplicablc) 1
rt. p.
348 Holiday Inn Dr. Kings Mountain, NC 28086 Cleve,
Physical Teddies.City.and Zip `1L REMARKS
Bentonite Seal from 27'-32'
Conch free:idnnlifc4iljun No,(PIN)
5b.Latitude and Longhtude in degm v-gminuccslscconds or decimal del recs. 22.Ce titration,
(1fs1Cl1 fVQld kMLL httflor1 is tnfl;ckni)
35 13' 23" N 81 21' 22" W Fir 10/30/2022
Sig€awn efccitified Well Contiactor Date
6.Is(ate)the well(s): EPer manent or ❑Teuiporary By signing atria form,1 Arrebl.ernifs Thar ilie irell(s)uvr(Mrne)canyinwitrl irr rrceonlaner
nirhl�t,YCAC42C.0t000PISANCACOIC.0200 WellConstairrlwrStarplardsandllyrra
7.h-this a repair to an e-tistfngwell: ❑Yes or ®No rryip ofrhir rrcnrrl hnc(»,,n pmridid rani,arrll mvncr.
if rtrfs is a repalr,fill rear kamivt x•ell carumrcrion brforrru,•rlon aril e_spbhr the oww"of dui
rrliair raurlrr t3?1 remur,Cssrefiern or rn the hruE of dres,(orne 23.Site dialram or additional well details:
You may use the back of this page to provide additional well site details or well
S.)`umber of wells constructed: 1 construction delairs. You mac also attach additional pages if necessary.
For mnhlple it ecrinn or ram-wirer supply wells ONLY mtrh the same coirstruaimr,yoareon
sut.Udi one forma SUBMITTAL INSTUCTiONS
9.Total well depth below land surface, ass r (R•) 24at. For Alt Wells. Submit this farm within 30 days of completion of hell
For aurrhiple wells list afldeprhs ffdif ervw(cmalpfc-3@200'aild 2@ IR9) con51meiign to the following:
10.Static water level below top of casing: (R) Division of Water Resources,Information Ptueessing•,Unit,
If hater level is choir wising,rise"+^ 1617 Mail Service Crater,Raleigh,INC 27699-I617
1L Borehole diameter:10 (>a) tab.Dr g -ion WeBv ONLY: in addition to sending file form to the address in
246 above.also submit a copy of thhis fottu within 30 days of completion of well
12.Well construction method: HSA/Air Rotary collstruction to the following.
ti-c.auger.rater,•,cable,direct push ctc.)
Division of grater Resources,Underl;round Fnjecdon Control Proggr••am,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Mcthod of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this foram within 30 days of completion of
13h.Disinfection 4-pe: Amount: vvctl con5fniction to the county health dcpanment of the county where
constructed.
Farm CstV-I Noah C=Ibu Depanmcni of Ea0mnnr_ut and Natural Resources-Division of Watcritesou Revised August 2013