GW1-2021-03105_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD For to=)Use MY:
'khn:rVM Can be asal for sib OF Mulfli 3c%IUS
1.Well Contractor tufottttatltm:
Brian Swing PROM TO OrAMM10114
well COVkMor Name
4240-B
NC Well CoonmrCenifewiouNnn>ber 7S.DVIER.LAL�tlSlt3 i�l[t ttt xtaed 1tTNi JIf^ Naib
FROM TO OTA15MM TtTK'KNFM MATERIAL
SASDACCO Inc 0 @, 35 ft, 2.25^ te. NA STEEL
16 I - fe=
C6I�f(1,Yil' tll�". .
FROM TO DtA.'VtE Ttllt'A'N'1LSS � I MATERIAL
fit.W441 Con0mcdon Permit#: R. ft;
Liu an aprt nwe wrl rrrmtrs(Le.cmorr,.Fmv Vorinnce,Nbcoat fir-)
R.
3.Well Use(etwdc well ase)
Water Snppla Well: FROM To Dt ptFTRR -y st'? -MIC.WNM MAYMAt,
DA�1kURItt81 auhmit°ipal/Mlic 35 R. 39 tt 1.25^ trs 004 NA STEEL
DSieothealla�l(tleating�CoOliog Sttppl}) DResidential Water Supply(siroc) tt;
OhrditslttallCoalmetnial ORcsidcl>tial Water Supply{slomd)
FROM TO MATERIAL WftACEMPxirML'IIIOD& O
t31in' odt R. tt.
Non-Water-%p#ly Well:
®Moniiotn G71te�
lnjanoll Well., ft: IL
DAgtlftftcharge l7GrovlidnttterReanediatio a.
(3A �Cr�t � R M TO. fA F a F.ilfPt=A, Ti'1M};TN.n�,
tpllt oWe and Recut 13S.alin4>lamct
OAftfcr Tend Mommidu Dminagc
fd. ft.
0Exppe[(mcnta)Tccbmtogy Mibsidcm Contest
f)tt)I.a2A"t� ti +s'ltach�idetiflerfik�` "" a�f;ni,cexsx. "=�.: , "
Mftthennal(Ciowd tAnp) OTracer FROM TO *
Cltataofhet"flk2ftv&oliM Return) 1301ba tn'under#21 Remaft) 0 fG 20, h. FILL SILTY SAND
20- (L 39' {4 WET SILTY SAND
4.Date Wetl(s)Co pieced 6-2-21 WeIiIDRTM-3 (L (L
56.1{eti Incatihin: tt. nt
Willis Grocery/Crossroads Pet Supplies R, #d: JON
pacilif}iClrceetlsar�x FaciliV MR(ifWpiimble) 5
� glt1C�
4025 West NC Hwy 10, Newton, NC, 28658
Physiml Add=&City.and Zip ,—21MMIXI
Catawba Grab sample with SP-22 via DPT rods
t„xrtr�sfy Pared ldamll'icmilauNd;{i�1N)
Sb.limitntloand laiughodeindegm0mitmtctsce6ndsor decimal degr 22.Certif`ecstion:
(lluefl field;ona to%va is(:+ttticieid)
r W >Br 1 6/9/2021
Sigmta of Cenifiod W�Canta�ctor late
6.Ts(arc)1he wtll(s)2 aPermanent or ZTemporary y �fgtinf clft latm t her rEy a re rsi r rite,rrtt{s)bavr l,a rr1 c�nrn rtrad in a�tionfimzr
wtdf 13A MCAC(l2te=01(7'or JJt ArCAC 02C.0Z We'a(+PMrMMOft S"r4drda Masot a
7.b this x repair to an existing well- Ms or MNn runs old racerM t«is te*e»pre ild4+d maiir nrtl op�eer.
Jf rAit is m re**.fit awkmp4w wellcaw4vtm t(omwtlmr woad mptadtr thn wwre rf dw
repnirwtdrrer31 remark xrohft or an d v bars`of dds form 23.Site ataga' m-or additional well dtttallx:
You'n*'use the baeb of if -,paw Io addi6ttral wi i site details err well
S.N'orhl tr of wells const tted: 1 e:anlstt Cdch details, You rosy also attach Additional pages if nemsaiy.
For mdrit4e/oijetrim of awe-»seer jW#,v xrttS ON Y,00 the ammo eansaar dad,.yom em"tMdtMW SURN1Cf'1 A1ti iR*C PtiMQPT
9.TbM'wdt depth betinr ixnd surrA= 39 {tk? 3Aa. Por A We11s. SAmit dds:form within 30 tit s of eonTWon of nirti
t"nrsutifpt, wilt 9i3rsttt*Fbr(/dtfertrlr#extrec±Ar10-M()tl'etsdMt3dlf constroctiantoftfQttowirw.
to.Static eater level below tarp of casing: (ft) itiw isi)n of Water Resoartcs,Idormation;Processing Unit.
ow if wr trvet if above ea A't&V^+" 1617 LMAD Service Clint rr,Raleit b,t�tC 27649•ttil?
1i.Borehole diameters 2.25 24b.l Qr Johan NO ONLY. Ito t ddition to seeding the foam to the address in
24a above, atsa submit-a copy of ib it form within 30 dal%of conVetion of well
12.Well constrottloa MgMed:DRIVEN catmiuction to the follbwh-W s
(i t:ar4ea:iftn-cxft din d pAk etc.) i
Division of iVaterResoorct,%tTndetgrtiroad rtjrctiala Control Program,
FOR WATER SUPPLY WNW[S ONLY: 1636 Mafi Senice Cet►ter,.Ralft.NC 276"4636
134.Ylrld(qpm) Method of test 24c.For Water SuMl•Yc in�txtioa 1Ydts:
Also submil one cop} of this foftit within 30 days of conVetion of
13b.Disinfection hype: Amount: well consimcti on to the county l hh dep itm it of(he count .Vitae
Fonn G%V-1 Akzth Cmotina U M of EwJwnmmA and NbtuW Resamnxs-Dh n or Wate?ReMMM RMK4 MOM 2013
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