GW1--04348_Well Construction - GW1_20230707

i
y •
WELL CONSTRUCTION RECORD •
Foz Internal Use ONLY:
This.form can bc-useil far single or tnultiple rwclls•
1.Well.Cpu[rtctoo Information: .
't.1:-.W 1TERLONES
Stefan Smith FROM Tr] •nPSCIHPTION
Well Cntyracior N;rrni. - ---- it. ft.
I.
ft. ft. •
3576A ' I •
NC Well ConttaclorC�ttifucation Nuwher IS::OUTER'CASiIG(forninTll-ea'cd'nellsl`OR LiNER(fi ai itieablel- ,.•.
•
FROM ' TO DIAMETER' THICKNESS MATERIAL
SAEDACCO Inc 0 • H. 10 ft ' 2" , le.- SCH-40 • PVC
I i INNER t ASING OR TUBING t'iKatberiifil'cWscdadi rl;
Con�run iravrC i__ _:-. .-.
• ' FROM „To • , DLAM FLTER ` THICKNESS • MATERIAL
2.Welf,tlronstt'netion l'cr i iit II: ft, ft,• • _ .'ill
Lisirdl applicable rcrrllp.Yrrrtilm fix.County.State.,Variamee,tll'abi i err l• - ft.
3,'Welt1.1.sc(shecicwell use): :17 SCltA:EN - - - .
Water Welt: FROM I TO ntt%tF.TTR sr•trTSOT, Til1CKNi 5 I MATIiRtal,
O:1 TTi.~ltlntra@ C11Gitinicipalil'ubhc 9 10 . ft:l 25 ff.• 2" in. .010 SOH-40 PVC
®Creotbemrat(ricatingrrCooling Supply)' .ORestdiitiaI-Watcr Supply(single) fi' i •r-- • ia'
•
•
i]luduslrialiCoutnts:rcial EiResidential\VaFer.Supplj'.(shared)
• FROM - TO. MATERIAL r EMPLACEMENT MEiTIOD.is AMOINiT
• ❑1rriputian' . . . . . . . . . . 0 'ft.. 5 ft,' Portland Pour
Nun-Water Supply Well: . .
• tMonilorint f3Rceoset}. . • . ft . rt. _,
injection% ell: . . It. rt..
0Agtufc0;ccharge. '- 1:lt7iOtindlwlerRotitcdia11011 ,192.SAND)GILL,YEL•IACK-iifappiieyTltil"•-- . ----
_ 'finom TO ttLyrnRFAL t:1PIAtIA1INT Ht:ruOu
❑Aturtfer:Sfor'Jgc and Rccocety (]Salinity Harriet' 8 . ft.. '25 ft. Sand ; 2
. ❑AgniferTest. . ❑Slornntiatcrl}ttiinagc. '
ft.- ft.
- L7k..petitnental Tcel •noio DSrihsidcnce.Cdnttol. .
2t1sDRILLIN G'EOG'fattielt'addltibn"sheets'if iteee'asnui•]
❑Geoiitenna1(Cltiset[Luup) ❑Tnicer mon '• TO D>scRIPTIO rwtar.l,:,ruiocs,,unA'r,Kt;Rlx. n sSik:,Ctsa
• ❑Geotliennal(Real,e C(1oline Return) ❑other(explain under, I-Remarks) _ 0 .ft.. 25 ,ft, .silt
4.Date;Well:(s).Couiplefcd:'-6-15-23 WelliD#MW-7 - .. yy = 'ems''; '".•
.
5a,Well Lecatina: .fL ft. • f
Pump N' Pak. .
ft,• ft, . �� .07 C1 20
,2�
Factlify CtnocrNuiuo Factt1tl•ink Gfappl'xablcl.. ft. p: Intri !, ,i - r7r `";i?:.7a3`ir
rasf; ts5!1f'
4994 NC Hwy 49 North, Liberty, NC, 27298 . . . ' ft. ft. . '
Physietll•Addiess_City..uird Zip ,2 L.REMARKS- • -
Randolph, 3 foot bentonite seal from 5 to.8 'feet. '
County Parcel h ailiflgUiari No;(PIN) .
$I1.I iltitude and-longitude in tlegreeslminuteslseconds or decimal degi'ces: -22,Certifications
(if wait said'.Ord lat,1oug i;nidricierrl) •
35.821361 N 79.573040 W •. ' }�/ 6/16/2023
.Siena. of Can-ad Well Contractor • Date
6.Is(are)the\Yell(.) ElPerntancnt or DTemiiorary ill,.i gnhrg(Fix faun;.)hereby e•errifY fbar Ilic((dull)rSTLY tint)) in,a d i,rw ore/roux
ivith'15A NCAC 02C.010O or Litt iVC,IC 02 C.;t)200 Well Coot rnieritnt Staodoots and:bra a
' 7.In-this areltair tit anexisti.ngwalk ElYes Ur ZNn , Ctyirafruitrerordhits brat provided roll,'r5rt:llrniier,
If thts'Ii a ripak fill pir Gnt'Oi:Well t'omtnt iboti 1i/irrrmortuii mirf e.epteith the tutrare of the.
repair ruder a?l,-:mirk:artaron or iii the!mirk of thix for,,, - '23.Site.dingrant or additioual wetl,detaiLs:
You may,use the back of this page to pros'ide additional rte11 site details:or Well
8:Itutuheroh ells constructed: 1 _ •construction details. You may itLo attach additional pages if nCccss:rn-.
• For irrnflt&htfeei?on or rtrttr-metre:slrpply rrrffs.ONLY with rtiosrtmr cotrstrttrtiwr,van girt
snitnrit axe farm. SUIIMITTA L iNSTUCTiONS_
9:Total welt depth betoir landsurface; 25 - • - . (ff.) 24:t..For All Walls( Submit this form within 30 days'of otimpletiau of'well
For irearlripieici•lit list of/drprhsifdtfi`rri,ra(example--;@2U,o'axul.2010.9) ' 'constructiontO thefolloninnr: - -
• 10.Static water level telow tap ut easing„ 14 . • (B,) Division of Writer Resources,infnrniutiun Prueessing Unit,.
.. 'If hike)crud is aLoer 614114,irsr'•+" 161.7 Mail.Serviee Center,Ralcighi,NC•27699-1617
11,Borehole diameter:8.25" (in.) 246:For;rrtjcetkln Subs ONLY: in addition to•seoding the fomrto the address in
24a abue: also submit a copy of this Toren within 30'days'of completion of Well
12,.Wellcatnstntetion method:HSA constntctiontathefollowing::
(i.e.aitoer,rotary,cable_direct posit,eio.)-
Dis4sion of SVater.Reseurces,Dudergr•ound G_tjectlon Control.Prograni, .
FOR WATER SUFFIX WELLS ONLY:' • - 1636 Mail Service Center,Raleigh,NC 27699-1636
. 13a,Yield(ginn) Method of test: 24e..For Water Supply&injection Weds:. , . -
Also.subinit one"copy of this faoti Within.36,daysofconipletibiraf
13b.Disinfection type: Amuuut: well'ctnstnictian to the crummy health department of the.county where
Constructed,
Form GW-t North Carolina Departmenr.of Envitorunenl and Natural Resources-Division of Water Rcatrcm Rcvised.Atraust 2.013