GW1-2021-03111_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD FerimmaltlscONLY:
'fhb Qy rm can be and for sf le or mWtiple rolls
1.Well Contractor 11tformatlon:
i4.:3�'11'R'h'a2 2b1?�
Brian Ewing FROM TO I MC9tInIO'i
%Veil C010mck"N4me ft. �t I
R. fly i
4240-B
NC Well Cor=*orCen;Ikmion Nui*er S,OUTER.CAMG ri W111-xteil. _ O1l<l dtiffmm s tlpb7c
FROM 7O nrAI rnul .SS I MAW.HTAL
SAEDACCO Inc 0 R, 20 (j. 1° ie. SCH-40 PVC
Comp iny'Nwr 71+.:t NC(tR lNG tl zte a
FROM TO DIAMETER77nCAh'� MAIM AL
AL
2.Well 6noraction.Permit
lid aft npptiruNe,wrd premier►i-r.t:ounri,Shoe,Variafwr.leg r&n esc.)
3.Wdl,Usc(check well ntc):
Water Supply Well: ! 'FROMTO I TAMRIVR J St, i- `r HCK:ti+MS MA7"r.RIAt..
DAgricultuml OMumicipallPublic 20 ft 25 h. I" to 010 SCH-40 Pvc
DGeothermal(Heatin000iing supply) +lResidential Wow Supplytgngk) R• � t"
olodustrinlfcom"=ial GResidemial Water Supply(st>azed) vROMOM. -
I TO . arA'reatAu, IMPrtatsMsv-r Msrrron ae AMoc.W
olrri a tion ft. fa
Non-water SUpply Wen:
MMonitori bRecoti
tojection Well: ft.- rL
(3"tiferltech:trge OCrtoundwaterRewdistion
QAgttfcr Stomgc and tccc�ruy p$stliniiy Harrier FROM Tp tATRR.tAt ern a. XT i91t n
18 M 25 h. FILTER SAND # 2
0Aquifer Ticst OStommVcr Dmin.;igc M h.
C)Ex*mcntal T=lmoiogy astowdc+icc Control
ARlI 'O G at(sicliitll[igdndl-6tiedslf'
oGeo t"nal(Closed Loop) 13Tmoer FRO+t To DFSCRrr Tto2C aabr 6ertn . siiaur r3 s�u t1c
oGeotbenutd(Heati ooli Retum) 00ther( lain under 02tRematl:s) o IL 201 h. FILL SILTY SAND
20' h. 40' fL WET SILTY SAND
4.Dw Weli(a)Coniplded: 6-4-21 WdIl M#TNW-11 h. (L
Sa.Well'ia)eathm: (t, h•
Willis Grocery/Crossroads Pet Supplies h. tt, .�
Farflk10%wr Nmae Facflih MR(if appi;cable)
ft.(.
4025 West NC Hwy 10, Newton, NC, 28658 h. f,
Ploskd Addle m City.w d Zip 7.21 . V
Catawba
BENTONITE SEAL 16 TO 18
Cook' 1}irsd ld:ntifrsstion tic,(14N)
Sh,Latitude,and Li6njotode in degmtsfininatestsec6nds,or decimal tl
(ttweltt'rcld,rate tafitang s ridfltk(d) 22.Gr7tit'rcato►n:
W —Brian- w i_ng.. — /2021
S;
6.Is fore)the well(s): t7Pertnanent or oTemporarg 11y.sWMR thlt forms I lkrdr,eeP f'r Thal the wens)was town.)lYairfruetttl in otrordmrar
alth I SA NCAC 02C.0100 or I U NCAC MC AM trill ComrErta Oon ShuWdr4s and dw a
T.Le this a repair to an dusting well: Mes or Me) eons ofrlri.r rsmll�aad+hv,prm�rlyd m l r:nrlt rnvnrr.
if t+4ls is a rrpMr.Jilllar karoYala nrll eoertautvlon fR{r�m+nlfan and rxpltr(n the�traarr i�'thr
rrtuir tehdrrA21...Mwerix asrNon or rsn the bdrf-nf thiv fame 23.Site dhWvm or additional well detal s:..
You may ttse the back of this page`to provide additional well site details orwdl
S.1\timber of wells constructed: 1 co»smetiondetails: You trtV also attach additional pages if twessarti.
For nwhipfe 147jft M or am-14wor swph wells ONLY 04 do mme canatrmrlon.ue+q ter+
nounieamfora �. AlT�.. t AI..IL�".UCTIONS
i
9.Total well depth below land surface: 40 {Ik) 24a. For A H t111. Submit this form within 30 datis of completion of A*11
Formilipte,I ellsM1ttt1depift1fdi)l'mean Construction to thefgtkminV
10.Statle Water level below top of casing: (f11,) Division of Water Resourtm InforatationProoe tslnp Unit,
If nrrsrr hart isa(aovr crtahrg,osr"+" 16tl Mail Service C nier.Rolci#b,li1C'2T647-160
li,sarebt►M diamctce 2.25 tiny) 24b.Fbr Inicetton M Wks ONLY: 1n addition tD sending the form to the address in
24a abod&also sc0ra t a copy of this fours within 30 days of completion of well
1.L NNIell aonstnn"on method:DRIVEN constntcdon to the foil ltg:
(i.e.stiffer.rotary.Wt.dins paste etc:) r
BN'ision of Water Under&ound Injection Control Pr+ogrM.
FOR WATER SL'PPLYI,VELIS`ONLY: 1636 Mall Service C.enter.'Ratelo.NC 23649.1636
i
131L Vidd(gpm) Method of tt:at: 24c.For Water Snit j Rt tnjeettot Wdts:
Also submit one copy of this forin iiithin'30 days of completion of
13b:Disinfection hrpc:, Amount- .v-cil constniction to the coimty hcatth dgmm uca of the courtly whew
canstrdcted.
Fcrm GW-t Notth Cwalfia lkpwftn of Em3mnmmd mid Mmral Rewwocs-Dh*bn of R+mcr�e wwtes Rcvbcd A&VA 2013