GW1-2022-10373_Well Construction - GW1_20221115

"WELL CONSTRUCTION RECORD �� Far hicival Use ONLY:
This form can be used for si ngle or multiple wells v\�
1.Well.ContractorLtformation:
t&AVATER ZONFS
Zach Thompson FRtprt TO DF$GRtt'f1tyN
W01 CorxradorNarac ft. ft,
R. m
4478A
NC Well Contracior Certification Nrrrcber 15:OUTERCASiNG for'ruuhlrayedisefJs"OR-Li, "I:l 6ible
FROM To DF:4tilETER 7T11Ct+. 35 MATERFAL
SAEDACCO Inc 0 rt 160 i (t. 6" in. I Schedule OPVC
Cmq;uty Niuw i6JNNER CASING Olt T BING( mtlermal cfosed400
FROM I To Di ATETER TnICFLNESS NIATERR IL it
2.Well Construction Permit#: R. fa in.
1-Wa1lrpplira6le wdipenvirs fi:r..Comity,Store,vnriarwr,Inyertirat esr..)
R. It. in.
3.Well use(chccl:well use): t7.SCRK"
WaterSupp{y Well: FR1111%1 MrL
DIAMETER SLOTSIZE THT(1CNFS5 MATERIAL
Mgricultuml ONfunicipal foblic R.®Geothermal(HeatipWCooliag Supply) ®Residential Water Supply(single) rt in, I
®hidustriaUConmlcicial ©Rcsidential WOtcr Supply(shared) I ia`GROUT
FROU TO NIATERUL E,%H?AM.MTN6r110DSAh10uNT
❑Itri anon ft. fG
Non-Water Supply Well:
ft. FL
®?V0I1itoring E]Rccovcry
Injectlon Well: R- R.
0AquifcrRcchaFge ClGroundmilcrRemcdiation t9YSANDlGRAVEL4NACK(if i0kable)`;
FRO'st Tp I MATFRIAt, F�fY1A(:FHF:NT Nt?HOD
17Aquifcr Storage and Recovery ❑Salinity Barrice R. ft.
❑AgnitcrTest ❑S(orm%atcrDriin,•to
❑Experimcnial Technology QSithsidcncc Conirul
26?11)RILLiIIG'LOG7attach additional shcda if ncccssan)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON roobr.bardncv wR'nickh in we,ctaF
❑Geodienual(HeatinetCoolIng Return) 00dier(explain under 921 Remat:Ls) o n. 65 IL Brown silty sand
65 fL 420 fL Rock
4.DateWeil(s)Completed: 9-21-2022 tiryte111D#RTKM 22-382 ft. fL
Sa,Well G.rcatians ft. fL o;+
nr
Albemarle ft. f( �6_ r r V U
Facifflyffiv ocrNante- Facilit)•IDN(ifapplimble) R• ft. N
348 Holiday Inn Dr. Kings Mountain, NC 28086 Cleve. . R. ft.
/ PinsicalAddress.City-and Zip >1L,REb ,; . t f ,r4
47 Open Borehole from 160'-4201 .,,rWDOG
Count} U PlArcer 1dcuGCicntiwr No.(PIN)
5b,I atitude and Longitude in degrmVininuteshecouds or decimal dcgrces: 22.Certification:
(Ifi,ell field,wie 101w gIs sicftickrd)
35.1251 N 81.2133 W 9/28/2022
Signature ofCcitilicd Well Coranctor Date
6.h(are)the weil(s): SlPermAnent or oTemporary &signing deli form,I hereky certify that 1)n ivellf k)is-=(Nrrrej contawcred nr accordance
ivifti 15A NCtC 02C.0100 or IBA NCAC 02C,0200 Will Constrfefimr Starkiards anti s1wr a
7.Lti thbi a repair to an existing well: ❑Yes ..or ®ND rq7rofrlus reconlbasbr.^n pmvitkd taflr imll owner.
rfrrtir if o fepedr,fill4WO A•n010 well convnieflon lnformrfrlon and expfaln Me itarare of tlic
repairruder$21 rmnarkvAmriaa oral din flack-•ofrids farnL 23.Site diagram or additional well details:
You may use the back of dill page to provide additional well site delails or well
8.Number of wells con atucted: 1 construction details. You tttav also atlach additional pages if necessary.
For ittaNple la ferA?n or am-%rarer supj4y wells ONLY rridi Me some constri itivn,you can
.mb)"it one form. SUBAfiTTAL iNSTUCTiONS
9.Total well depth below land surface: 420 (ft,j 24% For All Wells: Subndt this form within 30 days of completion of%tell
For nuilriple wells list all depths ll di Brew(e trmpfe-3@2017'and 2@ 100g construction to tile-following:
10.Static water level below top or casing: 45 (ft.) Division of Water Re_sourcLi,Information Processing Unit,
if nt<iter level Is above cursing,am"+" 1617 Mail Service Center,Italeigh,NC 27699-1617
11.Borehole diameter.6" (in.) 24b.Do fillallan 1 g112 ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this faun within 30 days of completion of well
12,Rreil construction method:Air Rotary construction,to life following:
(i.e.anger,rotary,cable direct posh CIC.}
Dlelsiou of Water Rcsoutres,Underground Injection Control Ptngranr,
FOR NVATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigb,NC 27699-1636
13a,Yield(gpm) Method of test: 24c.For Water Supply dt Injection Wells:
Also submit one copy of this farm within 30 days of completion of
13h.Disinketion type. Amount: well construction to the cotmly health department of the county where
constructed.
Farm GW-I Nosh Carolina D.-partmem of Ermirottnxm and NantrJ Resources-Division of Water Re- rces Revised Aygust2N►13