GW1-2023-00957_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD Fur TricnialUs_c.DNLY:.
11ils form can be us it ror.single or multiple n'elis-
1.�wtl,Cdntraaoe Inforurattotc
-MAVATL'R'LONFS
Chris Ru£fer 6'taOM R1 DESCRIPTION
W01 Coritrador Kane ft. ft.
4223-A � �.'Ei��
NC Rrcl]CommciorCcniftcalion Nun,bcr :..OUTER CASING(rur`erultl ci d'rccpsl'OR LINER rifts•
Cuahkl
TO I
THICKNF
SAEDACCO Inc
JAN 8 2023 0 O`r fL 40 fL 2 11 ta�TF r[?n hL SCH-0� PVC ncaL
('onrp;ury Now,' r�.•t r7fi C' '1�url1 6 INNER CASING OR Tt]B➢NG IggKiihLimil cku M4 ip
G[[O\i 'TO DGvnteTEx TMCti.\F.SS 3tA7'EnGI.
2.Well construction Pmulit Ri R, ft. 1L
L41 rillr.mikilble urllpenr+its rr:r,.Cnurttv.:S:u:r,.tradarxe,fil'a-dm en-.1' �--®
3.W t list{cbccl,rtiell use)..; -M SCREEN
Water Supply Well; FROM. F TO o1A%tF.TLR I sr.oTSM. TritcKYtss I mArrrrm,
iiAgricultural Cl Nit ilticipaU'Pubiic 40 ft, 50 'R, 21, in 010 SCH-40 ( PVC
®Gcoihernral(Beatingtooiiog Supply) ©Residential Water Supply(single)
rL ft;.
©ludustraUConintercial ©Residential NVatcr-Snpply(shared) .�oGRvUTM. ;To. ��ATER.INL cote[nc>h1EM AistTtaD s tivtourT
OhTi [tiara 0 ft. 36 f4 Portland Pour
Noti-W.0ter5upply�F'elf:
6dINignitcjring pRc¢ovrt}'
InJecllon Well: «. M
11A,411MrRccliarge CI1lrillr4maictRc6rcdiatiotl L9:S1ND1GILIVHL`PACK'tif rsl'sanbte►;'
-F•ROM. TO btarFt[rat. t srNr artvrF:�rvrtrerttn
O Atluifcr.Sloragc aW Rccevery ❑Salinity Barricr 38 A. 50 R. sand 2
❑AgnifcrTcst ❑Sivttnriatcr i3r;iinagc
rL. rt.
OEgiciinicntal Tccbn6to_q' ❑Subsid-cricc 6nirol
29.DRILLI GIVOG faltach additional sheets if ricecssant
E]Geothentiul(ClasedLyap) 0Trdcer FROM To Pr3SCRW110S(c»bnhardric+4 u,+l4nckrt "uAm,ctrl
❑(eothennal MeatinglCaoling Return? OOdter(explain under,421 Rematles) ry r4
IL rL
4.Date Well(s)Catulskied: 12-15-22 WdI lj)#Gw-23
f4 r4
54 Weil b[catian. fL See GEM' 3 Notes
Republic Services f4 Ft,
facility,Ut vacrNnnrc Facility tbM(1Cappi=:blc).
500 Landfill Rd., Mt. Gilead, NC, 27306 f4 rf.
Pit)sicalAddTss.City'_qhd Zill 3L RENIARKS
Montgomery Bentonite seal from 36-381; groundwater monitoring
(;getuly Nrcel Ideii ifioatiou Nu,(PW)
5b,Na itude'anif 1,ongitude In dc-p 1minutesfscconds or dccitual dcgrm: 22:CerTirication:
(lfirell I vid,ow bl101:is gldNk:rd)
>, W __Chris Ruffer 12/15/2022
Siolur,ofCcniGcd Well Contractor Daic
6.iS(are)lhC lvell(x): SIPI'rtllanenE or EiTemporan' f1,.idpfbtr.lirh farm..I hereby eerdife 0 of lltr lrePfxl Vvs(tsrre)evr�lmcde4"frrzrronhwce
ri'A 1511 NC1C•02C.r11-v or.l.fA+VCIC tie C,0200 Welf Cotrarr.;at'vn SruMards mkt fi.tw o
7.LS this a repair to an,existing well: 1=ves air ENu [tli r9f rlifr!rruirf bras been nrz+r'iifrd r?ih r at 1!rntrirr,
ll+hrs:lt a?}ur�r.fide r,rr frriirvr ri'rll,vrumrcrlard htfUrrl4;dtt�+r,rr+rlrtltlobt rltt'ngr+ue ofrfrc
ielirir raulcr 8?L iernrcrks sticrrm+oi•ran 1hrGru t of this fnrnr. -23.Site di.-rainror.additia nal vvetl details:
You play use d►e back of this page to ptov'ide-additional well site&uih�.or nett
S.Nusuberof well s constructed• 1 Construction deiaiis. You iffly i1S6 attach.additiouaf pasts ifatcc[ssary.
For+itarhleslujcMmte'ralm:11'cirersrrppfpireHs ONLY i0rhrhe.strvecosmijurritur,yea atr+
slGmfrww form. SUBMITTAL iNSTLTC-TiONS
?.Total sett depth below land surfae� 50 (fT.) -24m For Atl Wells: Snbmil this £anti tvitlrin 30 days of eomptetioti of well
For mathlplc icelf.fUsr rill depths if dtffewii(exvarpk'-.i @2M',vd.:Cn KV) construction to tierc foiloW ng:
f0.Statie.wuter level below tali of casiul:, ((t,) Divis'[un of Water ResouFC8.Information Processing Unit,.
if aster kcrd!v ithove easing,rase 1617 MaR.Ser vice Center,Rrlcigk,NC 276994617
11.Borehole diameter:6" OL) 24b.Fnr Rolectian LkRth ONLY. In addition to sending the four to the address in
2;aaLNoi'e, also sit mit a copy'ef this Earth wiffihi :tt1 day;s'of.completion of twit
12.Well oonstructiou rdethod: Sonic construction to the following!:
(i.e.aifix imary.cnbl'.direct pasts ctcJ
Diviiiait of Water[tesourom,Un&rgruund Ittjection Control Program,
FOR WATER SUPPLY WELLS ONLYf 1636 Mail Scmice Center,Raleigh,ETC 27699-1636
134r,Vicki(gtni) rdrad of test 2�For Water Sugtply&inicetioa WeRs:
Also submit one cop)' of this farm within 10.44y'sofcotn()letionof
13b.Disinfection type:. amount %cell construction to the cannily health dcpartinent of the county«•here
constructed,
}?pmr GW-t N..onh Cooling D.pagmcru.of Eoeimruucrn attd Natural Resources-Divii lon of tValcr R--attcess ke,,Ucd hugLu 2011