GW1--04354_Well Construction - GW1_20230707

WELL.CONSTRUCTION RECORD Far Internal Usn ONLY:.
This fanocan be-used fur.single or multiple wells.
• 1.'Well.ContractorInforniadou: • .•
. . -t1 Sr 'tERZONES . . . . . . . .
Stefan Smith roost - TO •DF$UUIPTIt}N '
Writ CoraractorName • ft. • ft, - I I .
•
3576-A ft. ft
NC1YdlCa>nraciarCcrtificalionNtilrltcr 15:•OUTERCASING'Chinitiiiflkedvr -WcIlsi'OR LINER tif:iij-Illcable)': - '. .
FROM - TO nrAtur tin• THICKNESS ' MATERIAL
SAEDACCO Inc '' 0 ft. 20 . fL .2" ' hi. SCH-40 PVC
Coatlrnni Name. '.Th INNER CASING OR TIMING! ,.6iheiiitarct tscddriuity, '
IIMTAME TO DIAMETER - THICKNESS MATERIAL
2.Wctt Canstttictirin ecru*II: ft, • It, 'lit.
/firirll applicable we'll peinaftx(La.County.l'aae,.VS'irioAc e,ftyap'eet eic•J' ft., ft. • iri
• 3,''t ri lElise(chccicwell use) 17:S4'Rfe.of - " . . .• . .• - . . .
Water Supply Well: . -._ -._ FNOM- TO DIAMETER • SLOTSVI: T1ItexNIsS MATRIU i,
C Agricultural ❑MuiticimtUT'Itbiic •
20 It... 40 ft. 2" inn 010 SCH-40 PVC
ClCieothetmal tflearingiCooiiug'Supply) .®Resudeiitial•Water Supply(single) - fi' ft III St1'
❑ludustrial/Conmurcial ©Residential Water-supply(shined) 'IoGI ROUT:.
FROhI tU MATEtttAL EMPI.ACE NIL"NT METHOD&A`IOUNi
Cirripntion• . . . . . 0 ft.- 16, .ft, . Portland Pour • .
Ntrn'NaterSupplyWell: ft. ft.
WMtlnitontig: I7R otrty
Injection Well: ft, It, —
.: COAgltiferRecharge . ClGroutiduatcirRciircdiatioa 1sisANolGu, VF.LP,►Ct['tu:ylidieantefr-_ _ --- --
'-E'Rt)I •TO . • SATr,RrAi. F:MPI,AC:!\II:NT ktt.`rtIOI .-
OAtlnifcr.Stotagcartd Rccavc ' pSlilinity Barrie( 18 It. 40 ft. sand 2
• ❑Aquifer Test DStormwiterIDrlitiagc fi.. ft,
DExp rintenlal TR.hnolotgy - IDSlibsidcttccCatgml 20:DRILLINf LOG'fatta Ii-additionai Steakifiteeessar Vi .
❑Geadtemial(Closed Limp)• 1:1Tracer" ' • FRObr . TO DESCRIPTION(valor.hartlnot.xiit'nrcht10N,O,Etn ackt
❑G odtenual(fleatinglCdollue Retmn) Elbilter(explain muter#21 RetuuthsI 0 .It. 30 • 'fL silt to clayed silt
30 ft. 40 -f.. silt/possible PWR
4,Date Well(s).Completed: 6-2-23 Welt 11D#MH-4 _
ft. ft.54.Well Location: .rt. •ft,
•, .e._4,1 Y x if
•
Shell.Gas Station . . It,. . It, J U i
023
Faci1Il Ow•ocrName Facility iDk(ifappIi nblc). • r -0�- {
R. ft:
171 Weaver Blvd., Weaverville, NC, 28787 . inF, t ' o-=. . :•a
rt, • ft.. fi`.
D1;s/t :;ritlt a
Ph}si^ul'r5itdrss City:.nndZip :.21 RIALtin c.S' .. .
Buncombe Bentonite 'seal from 16-18'
•
Canute• I'irec1I iliFiealiu nNo,(PIN) 1
. Sill t ittitude anil-Y.ongicnilc in tic grcesltninutestsccands nip ttccim iI degrees ILCciRiRration:
(dwelt Said,one Iatneeg is-sidnelem) .{� ,y
35.704470 N 82.569676 W .�' 1. :. �'+*""' _ - 6/5/2023
' Sift' ofCc..l-icdWellContractor Link
6.Is(Ire)thrrrell(S): BIPet7ndleettt or ❑Tetnporar}' lh•sfgning thin frrm..1 Thereby ccrofy Ibol 14 rr'Cdifs,1 was p4ere)L'w.iIrir[!ed FivaccorYldnc,-
•truth 1M NC4C OW,0100 or i5,1-NCr1C 02.0;02OO Wi U Corrstnrrrlon Sr uidaMs rind&a a
7.Ls this.a repair to an a istitt};well: f Y�y or No ' teyn'o}•diix rrrnnibo+beol provided rot.',..!in Fl mac,ie•r,
if hlc:icrr rtcp air,fill cart arran0.1(itch coni-tructhui iigc rrru:iipn anti e.rlt(abt the nitrate of the .
repair ander112l rnnark.'s alas or On the bark this form. • 23:Site diagram or additianni tseti detaiLs:
You may use the,back of this page to provide"additional tsell Site details;orti•ell
S.Number-of wells Constructed: 1 constlnctfon details, You'tay:iLo attach additional pages if necessary.
For urnlrlpie.fokesinn or'rrrui-Heiner supply weds ONLY irhfi(lie satrre eorrsrracllo t,ynn coo
.cobnrir mow f6ml. SUBMITTAL MST LTCTIONS
9.Total Well depth Gelow'land stirfaci; , 40 - (ft.) 24a..For All Wells: Submit this form within 31.1 days of completion of well
For ru.thipioioelk list riAdepilwifdifli-rorpImapafe-•3@e.2tk:`anrl @lO0'r ' consiniationto the following: • -
In.Static water level below tap of easing: . . ((I,) Div/shin of W'nter Resources,Infhrniatiun processing Unit,,
ifIrak.'hyet is i:bor'.•e.asiar,use"+" 161i Mail.Sci1'ice Center,Raleigh,NC 27699-IG17
1
11.BorehOle diamctem 8..25" (in-) 24b;For Injrel)1(r1'Wel,f5 ONE.Y: In addition to•seoding the form to the address in
24aabave. also submit a.copy of this form within 30 days'of completion of tell
. 12,\Veli eonstnreti0n method:HSA . 'constnictionto-the followings-' -
tic.euger,rotary.cablc,direct Musk etc.}
. Dlviyiou of Water Resource's,Underground Injecti0n Control,Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Midi Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection:Wells:.
. .14'Yield(glint) Method of test: s.
Also submit one'copy of this fanti Withal 30.days ofcouipletion.of -
13h.Disinfection tape Amount: wellconslnietion.to the county health department•of floc.county where
constructed.
Form GW-t North Carolina Dcpaamcnt.of Enritoitttxin and Natural Resources-Division of Water Resinr m ftcs'iscd Attgus32013
1