GW1-2022-10367_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD Far ttzmal Use ONLY:
This Conn can be used for single or mWtipk wells
1.WL41 Contractor Information:
I.A ATERZONES
Zach Thompson BROsi TO DKICRIV"ON
%voltCormragorNamc R. rl.
4478A rt. ft.
NC Well CaNmciar Ccr ification Number t5 OUTER CASUVG(fos'-mtitll eased wgis OR LTNLR(it a tica6kl,
FRObt TO DMNIETER TFIiCts�ESS \fATEli1AL
SAEDACCO Inc 0 (L 30' (L 4" is I Schedule OPVC
Cauip:uy-Name 16ANNER CASING OR: BING 'eaiherma]'clowd4oa
FROMTO DfAhrETER TEIECIGreSS 3fAiERL�I.
2.Wcll Construction Permit ar: ft It. '
L.hr all rppilrobf r twIlp nmita(Le.Counq,.Slam Variarwe,r1ya-drl efr,.)
R. R, tn.
3.Well Use(cheelc Weil asc): 17.SCR"N
Water Suppy Well: FROM TO DtAM:TFR SLOTS17E_ TnICK14USI'S MATRRiAL
❑Agricultural ONfunicipatiNblic 30' R. 150' ff. 4" hL .020 Schedule 40PVC
❑Geo(hefmal(Hea(ingtootiog Supply) ®Residential Water Supply(single) ft. I ft. in,
01ndustriaUConunercial ❑Residential Water Supply(shared) t8:GROUT
FROM TO HATER1AL EI[PLACEMENT NErH0D S AAEOUNT
❑hri ation 0 ft. 22' ft. Portland C +_ection
Nou-Water Supply IV&
®Monitoring ❑Rccovcry rt,
Injection Weil: rc, ft.
❑AquiferRcchargre ClGroundls:ltcrRemcdiation 4%SANDIGRAVELPACKfir agplicabk.Y.
FROM TA ,1fATFREAI. HAIN A(:F:NE.NTI1F:TnO11
❑AquifcrSloragcandRccOF'cr}' QSalinitpHarrict 27' ft. 150' f1. Filtered Sand #3
❑Aquifcr•1•cst ❑SlonmiaterDra tkgoc
ft. ft.
❑Experimental Tcchnotogy ❑Subsidence Control
20rDlRILLIlIG'LOG(ansch additional sheets if necessary)
❑Crotlremvtl(Closedtioop) ❑Tracer BRON TO DESCRtMON(color.hardnevk wil'mKk pytw, n tack:F
❑GLoft,ennal(Heating+CooBtigRelutn) ❑Odier(eglain under#21Retuarls) 0 ft. 1.5' (L Top Soil/ Clay
1.5' ft, 20' ft, Brown Clay and Mine Tailings
4.Datc Wcfl(s)Coutpleled: 10-12-2022 Wl'1l ID#RTRM 22-401
20' f4 150' (L Gray Rock
Sa.Well Location: ft. ft.
Albemarle R. fL `EV Li
FacL1ftp QvwrNama Facility WX(ifapplicable)
ft. ft. NOV
2072
348 Holiday Inn Dr. Rings Mountain, NC 28086 Cleve, ft. M
.: ._. .,
Physical Address City.and Zip 2I.REMARr:5
Bentonite Seal from 22'-27'
liuitrly Parcel It66idi5ici1lpnNo.(PIN)
5b.I-iEiitude and Longitude in dcgrceclminuteslseeonds or decinud dcgt'ccs: 22•Certification:
(lr%Vv41 field,Om Lmong Is sullicknl)
35 13' 23" N N 81 21' 22" W 10/30/2022
Signature ofCcitifled Well Cotuiactor Daie
6.IS(are),the well(s): EPermanent or ❑Temporary Br signing Mix farm,1 irerrby cerfifc rhar the vell(s)tswx(tsrrel cominrcmd hr avrorrlmicr
uirh l.4�t NC,1C fJ2C,Ul0±7 ar 15A NG1C 02C,{11tx17 n4l!Coustrnetiar Sranefards and rlinr a
7.Is this a repair to an existing well: E lYec or END en)ir orrhiy rccorxr hrrc(<•�i pr»v4kd rn r sn*ll rnvncr,
if ibis is a mlxrlr,fill oar kvt irn ivell vansm(crlon lrrforvrurrlon ivul arplatn rile rurrzne of rlir
impair ander 021 rcinarks serrrian or wr the bark of(Luis•foniL 23.Site diagram oradditional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells consimeted: 1 construction details. You,nay also attach additional pabvs if necessmy.
For mldflple hVevrhm ar awi-mtrer supply wells ONLY,,1rh the same cturstruedon,yuia can
rar}wlr one fumi. SUBMITTAL i STLICTiONS
9.Total well depth below land surface ISO, (D J 24a. Far AU Wells: Submit Uds farm nithin 30 days of completion of]sell
For oealrlple hells lrse aft deprhs 11 dl¢i rcnr(crcrniplC-3@2w,are!3�lt7(7'D construction to Cite following:
10.Static water level below top of casing: (f•) Divisinn of Water Resources,Information Processing Unit,
if iva.we level!r rLave cusing,ose"+" 1617 Mail Service Ccater,Raleigh,NC 27699-1617
11.Borehole diameter:8" (in) tab.Fnr 1[ohlinn Welflv ONLY: In addition to sending the fomr to the add rem in
24aabot'e,also submit a copy of this faun within 30 days of completion of well
fl2.R'cll construction method:HSA/Air Rotary construction to the followillg:
(Le.inigm rutap,cable direct push.e(c.)
Division of Water Resources,Undergound injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a,Yield(Epm) Method of test: 24c.For Watcr Supply&Igicetioa Wells:
Also submit one copy of this foetn'within 30 days of cotupletiou of
13h.DisinfeLtiun hpa Amount: well constmction to the county h�tlth department of the county whim
constnrctcd.
Fonu GSV-1 Nonh Carolina Dcpdonrm of Enairounictu and Natural Resntllees-Division of WaierReautes Revised August 1'O13