GW1--03535_Well Construction - GW1_20230519

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WELL CONSTRUCTION RECORD For Inictual Uso ONLY:
This form can be used Car si ngle ar multiple wells
1.Well Contractor Informatlotr
=1d:AVATER ZONES
Scott Hunt, Jr F14011r TO 1ANCRIMON
W01CairtradorNanty
4561-A
i
NC Well CanuacrarCcniftcation Number diS OUTEWCASlING tfoee(utti emit ricOsi OR i iNER iff a Ileable-.
FRONT Tt} Dr tET6R TntCt{, 5 MATERIAL
SAEDACCO Inc (L fl. in
Com p.-uq-Naurc 16.INNER'CASiNG OR:TU®ING° mehemd c1ascd4on
FROh1 TO DG\GEtGR IttlCtiNESS 31ATER AL
2.Welt construction Permit t 0 R, 5 ft. 2" SCH-40 PVC
lest allarPlirabla Calmly.State,,Pnriaaca Ir�erO'e�sir..)
3.Wcll Use(chccicwell asc): 17:st:Ra>F n
Water SupplyWelL• FHONI TO arANtF.T6& St SIZE T1IM"4M NIATnnIA1.
Clelgttculnual. ONfunicipatTubliic 5 ft. 15 R. 2" in. O10 SCH-40 PVC
®Geothermal(ReatingtCooling Supply) ®Residential Water Supply(single) ft- % to.
❑lndustrialfComancicial ❑Residential Water Supply(stared) �o17 RO[ TO arAreRUL` . EMPLACEN112NTAIRM011 s ANromrr
❑left alien 0 ft. 3 fL Portland Poured
Non-Water Supply Well:
Mmonitoring mitecovery ft,
Injection well: ft. 1`14
QAquiferRecharge QGtouwdu-niaRenicdiation 1%SANDIGRAVELPACKiir ttliubreV.
FRONT TO 1 N LTRnt,%i [tN1Y1 A(3�16Nr NiLrnpn
}]Aquifer 5toragc and Recovvciy ❑Salinity Barrier' 4 R. 15 ft. Filter Sand 1 #2.
❑AquiferTcst ❑Stommatcr l3r tirkaoc
❑ENperimcnial Technology 17Sttbs1dcwc Control
'20TDRILL-li1G:WG(trltachaddhiooel4hea itmem.s rv)
❑Gentlrgmlal(Close([Loup) ❑Tracer Flt0N1 TO DESCRUMON(mbr,hatdncsa wil'nick type.griln rift de 1
❑Geothemial(Heatin lCoothIgReturn) ❑Cuter(exphrin under.#21Rematks) 0 fL 5 ft, red fill dirt
5 ft, 10 fL cobbles
4.Date We8(9)Contpldted: 5-3-23 ttltcllIDtfMVi-22 10 ft,. 15 fL silty sand
54,Wdl Locution: fL (L
Crown Food Mart ft. fL MAY-j 4
Factlily)UivnerNamc Fddlily IDN(irappItable) ft. ft.
300 Rodney Orr Bypass', Robbinsville, NC; 28771 ft. ft ts,. 7K,•,r; (1:
Pk�i;ad Address.City.and Zip %21:REM1LARfCS"
Graham Bentonite seal from 3-4'
liwuh' 1saLel IderiliCLcatiou No.(PIN)
I b.Iartitude and i.ongitmde in Scgvices1minutCS/Sscands or decimal dcgr'ecs: 2L Certification:
(If%icll roold,Pate IaU7oi;gI girllicl rU) f
j� 5/7/2023
SlgruUMOfCcitifrcd NMI C tar Daic
6.Is(are)the well(s).- EPenu ment or oTemporacy By signing tbls form.I Irerehy eerdfv Thar•rhr n•ell(s)ts-=(meet}camuinrezed in aeeorrhmce
rvkh.IS.I NCSC 021C,0100 or 13el NC4C 03C.0200 Well Conshmcdon 8rarxlards aid date a
7.Lti this a repair to an evistingvvdh ❑Yes or ®No c r>ofdtlr recr+irlhirshrcn pia>vir&d((rrlN'ue!!(cure.
if ibis Is n p,a air,fill cvt kticnrvi xclleoru7n.ced�a lirforrrutrlon oral e.splaln die iiarure of rite
repair under 421 remarks se ion aran the.Meek of thisfarim 23.Site diagram or additional vsetl details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 coustniction details. You may also allach additional pages if necessary.
For stuilalplc lr�erdaror ami-ii'urer supple ivelL ONLY irlrh rhe.same conswiWIou,ww can
salmiitonc foma. C LIB btITTAL iNSTLICTiONS
9.Total well depth betow-land surfh= 15 (ft.) 24a. For Alt Wells: Submit this form within 30 days of completion of well
For ma&lpleivellslistalldeerkslfdl,Qi:rrrv(example-3@:00'%rid2@1 Wy con5lnietionto11Wfpttovving.
10.Static water level below tap of casing: 10 (ft.) Division of Water Rcsaur i%Information Pr6c."Sing Unit,
if it'uier level is above cvralmrg,am"+" 1617 Alail Sen'ice Center,Raleigh,INC 27699-1617
tt,Borehole diumctcr:6 (in,) 24b.at F jadon Wetly ONLY: in addition to.sending the form to the address in
24aabove,also subnrit a copy of this form within 30'day's'of completion of%tell
12,Well construction method: construction to due following:
(i.e.auger..n9aq',cablc"direct push.crc-I
Division of Water Itesourccs,Yindetgrouud Yttjection ControfPtngr�atn,
1636 AIA Serv'ice'Center,Raleigh,FORWr�TERSGPPI.YWdLIoSONLY: * �' .XC 27699-1636
134k1'ield ftni) Method of test: 24c.For Water SUPOV 44 Injeect!to Welts:
Also submit one copy of this fiinil within 30 days ofcompletioDof
13b.DisinfLetiun t_vpc Amount: well construction to the county health department of tiro county%'herc
corwtuctcd.
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Form GRr-I Noah Carolina Ucpamieni of Envifaanlnl attd'Nnafal Remurces—Division of Woler Rasotrces Rcviscd Atgust 20l3