GW1-2021-01200_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD � or lotermrl Use ONLY:
'this fgrmcan be osod For sinbtc or noiltiplc wells n
I.��'dt C�alttrnctortltlorlltatlan: \
1.1.:1i'A M'k ZONES
Robert Miller FROM iTf brSiRratyt?1
ft.2675 ft.
NC Arell Corrtmetar Ccnifi:'ation Number 15,OUTER CASENG(for rov ltl=ractd hens OR TJNER(if a ilcabk
FR031 TO IHAMFTER TrrICKNES5 MAMITAL
SAEDACCO Inc 0 ft, 35, fr. 2" ta, SCE-40 PVC
C'aaigr;nir'N71n1c 1 MINER CING OR i I)B1NG i c no cNrsed lair
FROM TO DU:1iF.TER TRICKNESS MATERIAL
2.Well Construetinn Permit : ft tt. 4L
Ulf all applirrr6le writ permira(in.Crlunty.81aar,Variraece,11a:dM err.)
rt, rt, ill.
3.Wei t.Ilsc(the cwdl ascl: �7 SC,NEEN �r�
Water surpkyWell: VROM Tit AMRTTtle 14TOTS17W I IMIC1CtM MATRR.uAI,
®Agticutt(trar. 35' N. 50 ft. 2" in_. O10 SCH-40 PVC
oGeothenw- 1lealingfCooli�Stpp ') ®Residential Aster Supp}•(single) rt' rV io DlndustrialfCommcrcial 13Residential Water Supply(shared) is.GROUT
BRON TO MATERUL I EtiPLACVdMTAWMODSAMOUNT
016i otion 0 ft. 31' fL Portland/BenTmiAte
Non-Water Supply We;ll:
WMonitorin ❑R�Drr R. tti
Tnjectioat
0Agoi(cr RcchaFgc OGrouudvm1cr Relncdiation 19,SAND , .,EL PAt .lie, r rllcitbt
r33
n_ TO dWfMAt, ttrt�pt a tr r wr rtr
❑Ai1uMr-StoTagc and Recavrr)• DSalinity 13arTicr rt. 50' A. Silica Sand 20/30
❑Aquifer Test 1384omm-atcr rho nax ft. ft.
❑Experimcntal Technology ❑&rbsidenec Control
2.0.E 11Rt1X1\O LOG'fattac6 addiiiariel shcels if dteccicssrv'1
❑GeQdtentwl(Closed Loop) ❑Trcer FAOH To pFscRIMO;;oobr.haranP s.}'3'r tstr tjOt'4 ct
❑Gootherual(Reath elCooline Mum) ❑tither(. lain rattler 92.1 RemarRs•') 0 fL 50' fL Tan Silty sand
rL rt,
a.Date Well(s)Conipleled: 1-5-2021 We]I ID#Mla-5
fL tL
52.Well Location: ft. rt
Dallas Food Mart rL (L
Facilhy;0wrrerNoroc Fac1hy 1D#(iraypliuble) R, ft.
2294 Smokey Park Hwy Candler, NC, 28715 ft. rc
Ptn•siml Address.City.and Zip -M MIARKS,
Buncombe Two feet bentonite seal from 31'to 33'
Ci,aWy Pined Itkartiricilion No,(PIN)
5b,Latitude and r.ongitudc in dcgruslminutalsecrinds or decimal dcgr'ccF. 22.fcrtiifecation:
(,irvell 1kid;(ma lattltltV is grafticicrd)
1/7/2021
Sigaatnceof�:;::c:r:f tF:": :.4::� - Daic
6.Is(are)the well(s): xPermanent or ❑TemR-a ,
11y.tiigning.Air form 1 hcret!t'aerrif}'door the nriljs/rsrrs{nrrx)rcmrrru[7cri in rrcreridimte
narh l M NCAC 02C 0100 or 154 N M-
CAC C,0200 Well Co�rFrmaimt Standards awl rlartr a
7.hid6 a repair tie ill exit/ing well: EiVe-v or �r{IB �� 2021 r4711T'nrrNT rrcarrii lags lh-en rnrvi(W rnil+r'aril moiler,
//rims LT a reMrlr•f114Mr Vf;W-.tr WeV ecwu-rnmloo htror wrrlwt enul1lwp-ralai real•owwre o f r1h,`jl i�
reltrrir remier M rmarkrsrchm or on rhr.hrark ofMis form. DrC,Car�!4`=:1 131.Site di4mkin or additional well detaits:
$ f�,401 r ' r^t,00 You may use the back of this page to provide additional 1txq1.site details or well
8.)\titnllcr of aelLc rnnstructed: 1 Ire ©`�1F',Su cxonsiturtion details. You may also roach addilionat pages if necessary.
For roue ph,1rliC'Crl[Mr or arvi-itywer mprdy rreffs 01VLY mlrh the same carntruesluur,y%,v can
s46jritmm fi7 m. SUBMITTAL IN T T .TIONS
9.Total well depth below Ian surface: 50, (ft.) 24a. For AH Wills: Subudi Ihis fouii wilbin 10 days of completion of ivetl
For rtrad ple 1vells hsr a(1erp;ft if doi!rew(exmnp1e•.t@i 0V r„ad l@ IM,'t consiniction tD like fcttlatning:
10.Static water level below top of casing: (n,) Diviiian of Witter Resources,information Processint;Unit,
lfItunr level tralcove casing,arm"+" 1617 plait Service Center,Raleigh,NC 2 7699-1 6 1 7
11.Borehole diameter:8.25" (in.) 20.FnP Injection Wells ONLY, In addition to sending the foml to the address in
24a abme. also submit a copy of this fort within 30 days of completion of well
12,Well eanctrnction method: 4.25" BSA consituctlon to the follal Iig-
(i.e.auger:rotary.cable diTez7 posh efc.i
Division of Water Resources,Underground Tojeclion Control Prmgrain,
FOR WATER SUPPLY WELLS ONLY: 1636 Alan Service Center.Raleigh,NC 27699-1636
13&field tltpm) lMlcitrod of test: 24r.For Water Supply&Injection Welhi:
Also submit out cop}• of this form within 30 days of completion of
13b.Dinnfection fi'pe:.__ _ -_- Amount:— r�Ttl consimetion to the county Itcahh depearnent of the crawly when
consli a d.
Farm GeV-t NoM Caraluu U7-annnc-m of E ivironmen and Nantral Resources-Dh ssion of Water Rmotiv s Revised August 1-0 1.1