GW1-2022-10372_Well Construction - GW1_20221115

9
WELL CONSTRUCTION RECORD I For Iricnial Use ONLY:
This form can be used for single or multiple teens
1.Weil Contr:lctorbiformation:
11DIASHR.ZONFS
Zach Thompson IrRONi TO pFyCRIPTIO
%V01CormradorName ft. ft.
4478A ft. fL
NC Well ConuactorCcrtificationNumbcr 15.'OUTER CASING fformutiieasedvtcFls'ORtINERQfa"tic�6k';
FRONT TO DIAMETER TFIICtti"tlE59 MATERIAL
SAEDACCO Inc 0 fL 65 fL 1 6" id. Steel
Com p ury Na"k, WANNER CASING OR TUBING' 'm1flwrn21 closed laa
FRONT TO DIAMETER I THTCtuNTESS MATERIAL
2.Well Constructi6n Pei-alit#: ft. ft, hL
List all applir-able well penreits(l c.t:arrnn,.Scare,Variance.Iry-abcn or..) f<. rt. In
3.Well t)sc(ebrxlc well use): i7:SCttEEN
`Voter Supple well:
FRONT I TO DIANIFTFI? SI.OTS17F, I TRICKNES5 I ;rrATRRiAL
DAgri ultund 0I44nicipallFttblic 65 R. 105 ft. 6" in. .020 Stainless Steel
OGeothemrtl(HeatinglCooliup Supply) ®Residential Water Supply(single) ft. 1 2
OindusniaUColuniercial ®Residential Water Supply(stared) I&GROUT
FRONT To NATERIAL I FAIPLACEMHVT NIEITIOD s ANtOUNT
❑llri lion 0 ft. 57 fL Portland C section
Non-Water Supply Well:
ft. ft,®hRanitoring QRccovcry
Injection Well: ft. IT.
❑AquiferRcc6argi QGiourrdwKlcrReawdiation 19:SAND/GRAVEL-PACK IN applicibleV.
FROM TO Nf,A'r$RIA[. fiSlPlA(4*.MV.NTNITn0n
QAguMr Storage and Recovery Qsalinity13anice 62 R, 106 ft. Filtered Sand #3
❑AgtiifcrTest Qstpirm atcrbraullau
(Z ft.
❑UxperiTncntal Technology QSnbsidcncc Canirol
'20rDRILLiNG TOG 7attadi additional stuets if ncccssan l
❑Geothermat(ClosedLoop) ❑Tracer FRONT TO DESCRIMON cobr.hardacvt.%unk1rftk tipt,ptinwe.dcl
❑Geotitennal(HeatinglCoolineRemm) ❑Odier(Mlain under#21 Retuaiks) 0 ft 55 fL Brown silty sand
55 ft. 106 fL Rock
4.Date Well(s)Completed: 9-26-2022 WL41EDtRTKM 22-387
54.�Vdl Ltrcatinn: fL ft. f
Albemarle IT. ft, NO V T
FactlityMuncrNamc Facility IDh(ifapplimble) ft. ft. 4
I
348 Holiday Inn Dr. Rings Mountain, NC 28086 Cleve, R, ft. 'I,
P
Plgsieal Address.City_and Zip r
'2l;REI1rARfCS
Bentonite Seal from 57'-621
Caauly Isarrel l&n4iricillgnNo,(PIN)
Sb.Latitude and Longitude in deglseslminutesJscerinds ar dccitn tl dcgtees: 22.Cer1i1reathm:
(iturll field,sox I tU7oug is wluckW)
35.1251 N 81.2132 W 9/28/2022
Sigalttac of Ccitiried Well Collimator Dale
6.Is(are)the{Pell(s}: EPermanent or Effempor'ary Nr signing this fain.I Irerrl r errrify rhar Mr,rrll(s l tray(tsrr,•i conrtrucied hr arxrtdmioe
n'iih 15A NC.AC 02C.01(k)or 15A NCAC.PC.0200 Well Constrrrrion Srarxlards and rlxrr a
7.is this a repair fit an existing well: ❑Yee or ®Nu roan ofrhir reeonl has N-ca prod&,d ro viva in:ll mater.
!f this b o rgvir.fill our keouvi dell cmurrucdoa blfibmxrfim ern!explaht the mirare of the
relnirumler 021 mnarks!rerun or an the bark:of dds farm. 23.Site dhntt'am or additional well detaits:
You may use the back of this page to provide additional well site details or well
8.Numberof wells constructed: 1 con tnictimt details. You rtlay also attach additional pages if necessary.
For Affahiple irderrluri or oar-iturer snppJv mills ONLY mlrh rile same constrxcrion,you.can
.a,bmit one form. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface:. 106 (D,) 24m For All Weiis: Submit this form within 30 days of completion of well
For mahlple wells list all depths f(differem(ererrnple-3@200'aixl 2@e 100) construction to the foltowing;
10.Static water level below top of casing: (B,) Dh-Wan of Water Resources,Inf rmation Processing Unit,
If unrerlfvel l;above rusfllg,rue"+" 1617 Mail Service Cecttcr,Rileigh,NC 27699-1617
11.Borehole diameter.8. (in.) 24b.Far in isdad Wella ONLY: In addition to sending the font to the address in
24a above.also submit a copy of this Iona within 30 days of completion of well
12.Well construction method:HSA/Air Rotary consimetiou to the folloSVhrg.
(Lc.auger.rotary,cables dimes paslL etc.)
Division of Rrater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Alai]Service Center,Raleigh,NC 27699-1636
13a Yield(gyre) tiicthed of test 24c.For Water Supply&Injection Wells:
Also subritit one copy of this form.within 30 days of corupletion of
13h.FiNinfectiun typm Amount: well constriction to the county health department of the ccnrnty wik-rc
constructed.
Fani GW-t North Carolina Dep"zoem of Emironrucaand I`IlEa al Resources-Divhlon ofWalerRmouro¢ Revised ALW t-VI3