GW1-2021-01262_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD \ FurlmmalUse ONLY
The farmcan be used far stook or muhgk wells
1.Well Caairoctor Information:
11 WATER ZONE&
Robert Killer noM TO I ism-n ,"ON
Nell Co mw o,Nam fl. rL
n. h.
2675
NCW'eO Contractor Cemlicaiwo Nutrber t C
rROM AS DIAMRIR 7711CKA1[aS NAT[alAl.
SARDACCO Inc 0 IL 1 30' h. 2" te. SCH-40 PVC
Coepmn Name
mom I D Mffwx TRW7LNtls MATTRIAL
2.Well Construction Permit it. ft. 1 h. I ift
liu ufluq,li:vbfr.rlf pr,mib fi.r.frwn(r.Shvr.1'urixmr.fgQ0u1 m.l
11. I n. Is
3.Well Use(check well am): 17.scam
Water Supply Well: "OM I TO mAMITRR MATasra Tnt(T(Nmhs MATIRIAL
DAlincuhu2l ❑Municpalllttrblic 30' ft. 40' IL 2" is .010 SCR-40 PVC
❑Cteothenlril(Headr%coolirtit Supph) UResidemial Water Supply isingle) n. rL ra
Oltdustrial+Comnlercial DRaidemial Water Supph (shard l 141.GROAT
shots TO MATERLAL IMPLA TMRNT MEDIW I AMOUNT
E]IMUAWD 0 h. 26' (L Portland/He s•.r.alw
Noa•Waser Supply Well:
rl. R
® ❑Rmmrir
ti a
DAiluft iecharge OGroundxaia Remeditdon so. VILPACR
❑Aquifer Stofageard Recmen ❑SRhMny Baffler M MATt NI. IMrI.ArTYItT NIT
28' Is. 40' R I Silica Sand 20/30
❑AgmkF TC54 ❑Stomsraver Dramage h. R.
OEVemeental Tochnology ❑SUbsidence Comml
OGeodwrnwl(Closed loop) OTraat FROM TO DsaeRrPITOM srYr.a .hwMm arit,wrA
OGeothermal(Rcob#WXoohvg Remml DO(her qexplam under a21 Retnariz) 0 (. 29' n. Tan Silt
29' h. 40' is. Rock
4.Date WeRls)Completed: 1-14-2021 Well IDMRK-11R
h. h
5a.Well Location: it. IL
Pilot 393 n. h.
Facilo,O.rer Name FKIM1 IDelifapplicibkl
n. n.
3712 Crabtree Rd. , Waynesville, WC, 28785 h, R
Plnsical Adiresc fin.and Zip 2L RLV AM
Haywood Two feet bentonite seal from 26'to 28'
cents? Parcelldcmdreannu No (PINI
5h.Lxdode and LORRImde In depee"dualnhecank ar deelmd degrene: 22.Certification:
ot.eu Ikd.one h lomg 1..dfcxno
1/17/2021
DW
6.Is ism)the wellis): ZFelmsmtm or oTemporury q+ tenor thu h... I hmbr rrnif era be vrf l.').ar f.r,rl,nowt."d or aarons :
tech 154 AWAC OX.Of l or I5A NCAC OX O1W Well Congm nos Sa+.dauds wd dmt a
7.Is this a repair to an czkd"well: ❑V= or ENp .+Pr n(rhu rc.r.ri bag M,*Pmrdrd m rh.r77 n.•nrr.
If,hius x critic I f!ear erouxu.Af+auarv.rton+lnJtirxurpon,nw7 r cPlnm rlt rortarr of rhr
rrpcir uMn I`I rcmurl+arniut a rw de hurt of this Dorm. 23.Sloe diagram or adrhllMaal well deraih:
You am'use die lack of des page to pms'rtle additional well site details or well
S.Number of wells constructed: 1 construction deg". You MR%am ahau h o"hooai pagan if aa:euen.
Fm mdrrfdr+n(eron.m owl-n.Nr u+PPI,.rile OA'LY oath r!r wet avniba.•tlea.ww,am
axbmir.wo-jrvm. CIIRMIITAI.Q4STU('T1ONC
9,Total well depth Debw land wrface: 40 24, For AN Wells: Submit nhrs form wolim 10 dsys of completion or well
For salnplr.'elh liu of drlxb,lfdefnraa,rrawp1e-?OZ r1d tp constriction to the following'.
ID.Static water In'd helum by of easier a 91121 al Ilh isims of Water Resources,lafprmatiw Processing Unit.
o veak,lv.rl a rrin.r,uuxr.u,r"v" 1617 Ma8 Scn'ice Cater.Ralrigh.NC 2 76 9 9-16 17
11.Borehole diameter:6" Ita.l 34b.For Intecdom Wdh ONLY: In addition to sending the form to the address in
+ ,. 24aabm'e. also submit a copy of this form xhhin i0 days of completion of sell
12.Wen eoasteuYhru m " A
ethod: 6ir Hammer '�...: mmtni:uon to the following.
li c.asp or.roar).cable.diva pmh oc.t
Dhhlon of Water Rtswrca,URM'pMrad ItiJettiaa Central Propam.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen'lot Center.Raleigh,NC 27699.1636
In W
134.Yteld(win) Method of rat. Zoe.For Water a coln of lactose ithi
Also submit ore mpy of this form gotten Nl days of crotlhpktioR of
13h.OWafeedon type: . _. .__._._ Amount: well construction to the corraY)' Mach department of the coumy where
corMntcied
FomGW-t Nonh Carolina D.gsom a of Em son mot and Narwal RCWWCC[-Dn son or Water Resources Ro ucd Akgua NI 11