GW1--00814_Well Construction - GW1_20240131

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WELL CONSTRUC'I'EON RECORD For infernal UscONLY: • '
This form can be used for sinrk or multiple wells
I.Wilt Contrtitor Information: .
'.ti:WATER ZONES I
Rich Lemire FROM TO t DFyCRiPt R)N I
Well Contractor Name _-. ft. ft. I
2593A '. '1•,..•r J rai 3.:1,1) ft. ft..
NC Well Corti sclorCeni@eatian Nnrdrei t JA J` AS.OUTER CASING(Cormutli-efved eiRs1 OR-LINER Iif un livable).
3 1 2024 FROM TODIAME
TER illIC NEES• MATERIAL
SAEDACCO 0 fL 10 ft. 2 Diu. SCH-40 •• PVC
Company Name, In, r(;s;:F•ri p''.^,,,,-�: i a ki.INNER CASING OR TUBING ollmirinal cr .cd-loojm) .
D'ry kX3Lti7 FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit a: R. R. M.
Ma all cpalicable well permits(Le.County.S;i M,Variance,Thject err elm)
•rt. II, nt.
3.WclL.Use(check well use): 17:SCREEN
Water Supply Weil " From. TO DIAMETER SLOTSPPE T111CRNNIS I MATERIMI,
DAgricultural DMunicipiiUPublic 10 ft, 20 R. 2 in O10 SCH-40 PVC
DGeothennal(Heating'Cooling Supply) °Residential Water Supply(single) ft. it in.
OlndusifiallCotttniercial ®Residential Water Supply(sL tmd) t8:GRUUT.
FROM TO a[ATnRfAL Ea[PLACEa1SVT METHOD&AMOUNT
IDkiipnlian 0 ft. 4 ft, PORTLAND TREMMIE
Non-Water Supply Well:
®Monitoring IRecovery ,
. Injection Well: ft. ft.
°Aquifer Recharge 0GroundaaterRentcdiation t9.SAND!GRAVEL4"ACK(if appth:able)"
FROM TO' MATERIAL' ESIPIACEMENT MITER)n..
°Aquifer Storage and Recover)* °Salinity 13ariict 8 R. 20 ft. SAND #2
°AgnifetTest tDS1onnn;ttcr t}rainagc ft. ft..
❑t xperimcntal Terimolo ' °Srtbsidcttec Control '20.DRILLING LOG(attach additional sheets if necessary)
DGeotknna[(Closed Loop) °Tracer .Fnoat TO DESCRIPTION taroar.hadsmt.wirratkDm:grata size.rent
❑Geodiemal(Heating Cooling Return) DOther(explain under A21 Reinatl s) 0 :ft. 20 ft. RED'SILTY�CLAY
It. ft.
4.Date Well(s)Completed: 1-4-2024 .Well IDt(MW-42 '
ft. IL
5:1,Well Location: ft. ft.
GASTON COUNTY LANDFILL ft. ft.
Faciilit'a'OtrrierNarnc Facility ID k(ifappli:nblo) ft. R
3155 Philadelphia Church Rd., DALLAS, NC, 28034 .ft. ft.
Physical Address.City.and Zip', ,2 L.REMMARI(S
GASTON BENTONITE FROM 4' TO 8'. l
Camay Parcel Ideeliftealiou No,(PIN)
SI►.I:atitiidc and Longitude in(fegrccs/minutcstscconds or decimal degrees: 12.Ccl'titicatiRn:
(if n'ell lick',on4 lalflay.IS idtlecra) -
N W -- ti....L. 1/6/2024
' Sigtuturcu[Ccni WeilCannactor Dale
6.Ls(are)the\\'CII(§)r XIPCtLranettt. or OTemlarnn' ley signing rids form,I hereby cerrif)'that the well{s)was-jnrrej constructed an accordance.
with 15A NOW 02C,0109 or 15,1 NCrtC 02C.0200 Well Construction Staidards and Oral a
7.Ls this a repair tit an existing,all: DYes or KNo c rJirof Mir record has Lem provided to the aril turnen
if MU'is a rep.r1r,Jill rot(s'airrr well construction irrformarnn and espial)!Area nature of the
repair tauter*?1 rcrnarkrswami ortm the b,wk Of this ferny. .23.Site diagram or additional welt details:
You-may use the back of this page to'provide additional well site details or well
S.Mother of wells constructed: 1 cotisttuctimt details. You war also attach additional pages if n ecessan-.
For multiple Infection croon-warer suppJi•wells ONLY with rho mine construction,you can
sabnru:nne farm. SUBMITTAL iNSTUCTIONS
9.Total tt:elldepth below land surface: 20 (ft.) taut. Fur ALL Wells: Submit this form within 30 days of-compietion of Well
For nuthi e'oellr list all Acpths ifd:i'rrnt(crarnpte-3@2OO and 2@ 100) constncction to the Cottoning:
10.Static water level below top of easing: 8 (D.) Division of Water Resources,Information Processing Unit,
If wave level Is above wafting;are"+" . [617 Mail Service Center}Raleigh,NC 27699-1617
11,Borehole diameter:8.25" (in.) 2-lb.For Infection Welts ONLY: In addition to sending the form to the address in
24aabov'e.also submit a copy of this form within 30 days of completion of well
12.Well construction method:AUGER construction to the following: ;-
(i.e.auger.rotary,cable direct posh etc.) 'DIviSi()tl of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699.1636
13 t Yield(gpm)_ Method of test: 24c.For Water Supply&injection Welts:
Also submit one copy of this faint Within 30 days of completion of
well construction to the county health department of tie connlscw•here
13h.Disinfection type: Amount: - constructed.
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Fann GW-L North Cunha Depmrnrc ul of Enviroutrrn and Natural Resources—Disiiion of Wafer Reorrc Revised August 24Il3