GW1-2021-01235_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD
For iraanml LJsc ONLY:
This ra,m eon be used Car singlcor mulliplc n,clls
1.Well Contractor Information:
1r..irnTttt 2t1ivES
Will Keyes FROM I TO ORSCHIP110
W01 Cualrrgtnt Kamm R. R.
rt,4220 A ft.
NC Well Couirrdor Cerlifocation Nunrbct 15.OOMUTE R.CASENG Mir mufti-eased*co (if.s'OR UNTM a Rcable)
FR TO DLA1fETEft ,TrifCK MAT"TAL
SAEDACCO Inc 0 fL 1 17' fL 2" ia. SCH-40 PVC
Carnlr:ury.NOOK 16:JN.lIER CASING OR BING('errihemial closed4-mill TO DIAMETER THICKNESS MATERiAL
2.W'dl Congtr action Permit#: R. ft, uu.
Liu allnppii able wdl prnnifi fir.County,Sumo,Variomrr,Tnfs-rtiat rlr.J
ft. f4 in
3.Well i}se(chcdi'"Al per): T7 SCItit3 N.
Water Supply Well: FROM TO I ot.►METrK 1-MOTS117% I TtTtt:"KNTS9 I MAT
ttRr It
DAgfich ltural OlMu ticipatTOlic 171 rr. 471 R, 2" In Olt) SCH-40 PVC
®GeolhCP-Ml(1#eatiFaCooling SliUply) ®Residential Water Suppfp(single) p. It. i�• 1
❑IndustriaKommercial DResidential%laterSuppb--speared) FRoL�if To arAMlteAi I E+tvuCtu�rrtL-nlon&w`touNr
❑lrui Lion 0 R. 13' fL Portland poured
Non-Water Supply Well:
llGhlttnitnrinG_- - ❑Rccavr R• R.
injection Well: fL fL
DAqu*r Recharge 00roundwatcr Rcuicdiation 19.SANb1GRAVEL PACK(ir t lieabte
FROM 10 _ M;•YMAl. Mr-r11( )
❑Aquifer Storigc and Rccn,tirry 05alinily Barrier 15' ft. 47' ft. sand 3a
❑Aquifer Test ❑5tommmtcrDmt;nmW
❑t xpctimcntal 7bchnotogy ❑Snhsidertcc Curdmpl
20:AR.TLt.1NG'LOG(attach additional shoats if am" n
❑Geothemual(closed Loop) ❑Trcer .FROM TO DFSCRtF'TIOv c»br,hsrdneT+la_tt'i+rcSir nc�c,e/ca
❑Gc9 henital(Heath s1CooL{Me Mum) ❑Odler tit lain under#21 Remarks) 0 ft. 451 fL saporlite
45' ft. 47' ft bed rock
4.Date W'ell(s)Ctlmplefed: 1-13-21 Weal]DffEW-1
a. rL
5a.Well Locathin: ft. ft.
Wells Hosiery Mills ft. (L
Factliip,'Otsncr Namc Facility iM(if applicabic)
R. R.
1758 S. Fayetteville St., Asheboro, NC, 27205 ft. fL
Pllyikal Address,City.and Zip -1t.RMARKS
Randolph Bentonite seal: 13-15'
t iwnny' PArmd Idorwrie lim No,(PAN)
5h.L atifudc and L.nngitudc in dcgrvcs4minutes1second5 nr decimal deg v": 22.Certification:
(Itmell field,rgrc Lu7cr is ardTi�letrft
r �
35.681414 N -79.821353 �} rr t !±• � 1/18/2021
Sigcninrc ofCen_iscs:Wall Contractas Daic
6.Is(are)the wdl(s): xPertnanent or ❑Temlrtrrary fh,.WgmMy whir form,I hercby ere ifr foal the wrlifa'I Has(Karl rem4lnrelerl im mr.-rdance
iviih Iy t NCAC MAIM or I SA j%10W 72C.0,!M Re,11 Consenvafan Siar4irfs rind M.-Tu o
7.Lc thibi a repair to an existing well: 0Vcs or K Nn rrVy(Ifilik reconihos ht m pmri*41 rnrhe oy-fl4nenrr.
if rbls is m relxrlr.,fill4mr kmrntmi well r ismo^rinrr brfcrowrlrm cruel exp6hi the narvre o lw
relmir rmdrr 021 rmnarks.rrrlimn or an(fir bra-1-ofMis form. .��" fq 23.Site diagram or additional well detain:
You may use the back of this paw to provide additional well site details or wet
8.Number of wells tronsirttcted: 1 � constructim delaRs. You snap also attach additional pages if twc:essary.
For itmhWe irtimrko tv arm-warer W.rd)wells ONLY 9vidi the same ronsrrar
aufNnif nor forme, t d �' S�%f TTAL-INST11CTrOlvs
9.Total T1 ea!depth helms land surface-, 47 -.•n(° 1; "34a. For All Welly Submit fill fomt Wilhin 30 days of completion of tvell
For mmkipia..•ells Hstvfl rtep*s irdlf errrir(earm,nie•.r^?fit3',ra�d'r�.{fiidi'_ ' t�.t]� conslniction to the follovsin
10.Static Hater level below top of casing: 12 (1Y) Division of Water Resources,Information Processing Unit.
if rvaler Level is alove wising,eat•-+" 1617 Slail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:4 (in.) 24b.For i than Wags ONi j% !n addition to sending The fumy to fire address in
24a abme. also submit a copy of this form within 30 daps of completion of well
12.Wc11 c[rncirfiction rpethod: sonic construction to the followilkir
(i_c.auger.radar}•.cablc.dins posit ctc.)
Division of Water Resources,Underground Injecilon Control Program,
FOR WATER SUPPLY\YELLS ONLY: 1636 Mail Service Center.RaleipJr,NC 27619-1636
13a,Vidd(gpm) Method of test: tie.For Water Supply&lnlcctiiin Wel!<ci
Also submit one Copy of this foam v+tthin 30 daps of completion of
13b.Disinfection th-pe:,_._ ._ - .__ - -._ Amount.._ _ well construction to the county 16alth dcp,artm it of the comnty vvhrmc
constructed.
Fann GW-1 North Camlhm Dcpnnmmu of Su dmi umm and Narural Resources-Divislon of Wake Rmto rm Reeked Augtrst'2413