GW1-2022-10368_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD Few trs=1 Use ONLY:
'this form can be used for single or maltipk wells'
1.WL41 Contractor Information:
1:1:.t1'ATER ZONiS-
Zach Thompson FROM TO pri.SCRIMON
1tell Loan.gorNaote ft. ft,
4478A fL I ft.
NC Well ConnaciarCertifimfionNurber 15:0IITERCAStNGtrbrki it ifnc(Isl`OR=LiNER(i" ticabk
FRONT TO DL VETER TrrrCRtdESS htATEPTAL
SAEDACCO Inc 0 fL 1 30 ft 4" in. Schedule 0PVC
CdnVany Nadu T&MNI ER CASING OR: BING mibermal elased4oa ,.
VRO3I TO DLL\tETER THICKNESS. I MATEIUAL
2.Welt Construction Perrult#: R. ft, tl►
I st ollapplicable roll pvrmits(Lr.Coanry.State,Voriaare,lnperdvl r:r_)
3.Well Use(chcd:wdl use): 17:SCREEN
Water Supply Well: FROM TO DrANIMR SLOTSiU TiOCKNEbS I MATERiAL
❑Agricultural ❑hfunicipal/Public 30 ft. 110' R. 4" in, 020 Schedule OPVC
®Geothermal(Yieadogitooling Supply) ®Residential Water Supply(single) ft. fL in.
®industria lConuncicial ©Residential Water Supply(shared) 'TR GROUT „
FROM TO NIATERPAL EMPLACEMENT htEMOD&A31OUNT
❑hri ation 0 fL 22' (L Portland Ce3 aintection
Non-Water Supply Well: (14®)Monitoring pRccoacry Ft.
Injection Well: tG fl
O Aquifer Recharge ❑Giouridrmtcr Reatcdiatian t9 5ANDld.ILtVEL t°ACK(if artifficAbky,
'PROr! TYi EZ\lPt..v(:F:TtVYTMtTROn
❑Agnifcr Storage airdRccav'cry' pSalinite 135rricc 27' R. 110' SIAURIlS1.ft. Filtered Sand #3
❑Aquifct-Test ❑StommatcrDrainage fL tt.
[]Experimental Tcchnotogp ClSubSidcnCC CotOwl.
'20 DRILL➢NG'LOG7auach addiiional.slim4if accessarvt
❑Gcothertnal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hnrdncv wR'mckir a ptin E*se.dGI
❑Creotltennal(ReatipgfCooUugReturn) ❑011rer(Lypbrin under.921Retnatls) 0 fL 1.5' ft, Topsoil/Brown Clay
1.5' fL 8' fL Mine Tailings
4.Date Well(s)Completed: 10-10-2022WetlID#RTKM 22-399 8' ft. 110' (L Gray Rock ti
Na.Well Location: ft. (L
P
Albemarle M 1L NOv r
Factlity)'OiwrxtrNamo FactlitylD9Gfapplicable) R. fti
348 Holiday Inn Dr. Rings Mountain, NC 28086 Cleve, R. f1 ' J:l
PlrysicW Addicss.City-and Zip ;-2E RERtARKS kil7k
Bentonite Seal from 22'-27'
CaruWy Nmel 1&311 r11iwt No,(PiN)
5b.Latitude and Longitude in dc9meslminuteslseconds or decimal ftrces: 22.Certification.
(ifuiM ricw,wie LWorrs is satM04w)
35 13' 27" N N 81 21' 21" W W 10/30/2022
Sigrutum of Ccaifred Vicli Cantiaetor Date
6.Is(a&)the lvell(s): MPermanent or oTemporary in.afgning thin farm•i hereby rerrify rhar shr,trll(s)was(mrni conitnicred ire a Lvvrdance
with Mot rV0W 02C.01()or Uel NCAC 02C,02M Well Coustrucrion Sraddards and raver Cr
7.[s this a repair to an misting well: [WeN or ENo coliyofdiir record has brat pmvidW r:Or imll(poser.
If This is a repair,fillreitlatoim x'rl1 ewu7tricrtaa brforrrutrinn mull atplabt der twnirc ojrhr
rrpairranler#271 rnnartvxecrion orwr the bark-ofdris fornr. 23.Site diagram or additional%veil details:
You tuay use the back of this page to provide additional well site details or%ell
8.Numberof wells constructed: 1 construction details. You wav also attach additional pages if weessary.
For ttudriple fiyeCrlon or oan-warer supply'ivells ONLY il'irh die same construcliou,you cam
salvightnetome. SURAILITAL.iNSTUCTiONS
9.Total well depth below land surface. 110 ((I,) 24a. For All Wells: Submit tWs fame within 3U days of completion of well
Fortntdriple wells list alldepilisifdifferertr(erarnpfe-3@2(r0'arul2@1IR1) construction to(fie ffoitoning:
10.Static Avgter�level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if irwer level is rhave rasing,dsc"�" 1617 Mail Service Center,Ralei-,h,NC 27699-1617
11.Borehole diameter,8" (in.) 246.For jH1Mggn Welly ONLY: ha addition to sending tine form to the address in
24a above.also submit a copy of this form within 30 days of completion of Hell
12.Well construction method:HSA/Air Rotary constructiou to the following:
(Le.auger.rotary cable direct paslr.etc.)
Division of Water Rescutres,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i636 hfail So-nice Center,Raleigh,NC 27699-1636
24e.For Water Supply&Injection 6Vdls:
p3;ta Yids(gym) Method of test: Also submit one copy of this form,within 30 days of completion of
13h.DiAnketion t<•pu Amount: well construction to the cormty health depamncnt of the cminty where
constructed.
Fomi GW-r Mirth Catalina Dcpannicut of Em'ironnient and Varural Resources—Division of Watr.rRcnoutes Revised ayguA 2013