GW1-2021-03116_Well Construction - GW1_20210625

WELL CONSTRUMON RECORD p�lr ,lIlse<r)nv:
nis fom can used for si4k ov smltiple antis
1.Well Contractor larom tion:
Brian Swing rnQM 19 005CIRW ON
11tt1 t o lRS cw Nam
R. ft
4240-B
NCWC11ConmdarCenifacailotsNnnbcr FR011llPdt.0 INti riinCi'tii4anacd -, CiTmeyM
FROM TO r1tiME't'h�• TltfCK"tR.35 MATERTAi
SASDACCO Inc 0 (L 30 (L 1" he: SCE-40 PVC
Cear 'Nal>we
1'o.I R 498 G rat ... hop
rROi4r TO DlA24Ii.Ttit TiCIC[+`R'P.S�r � MATERIAL
2.'ell Gtnntaactiun Pcrmft
flu ttt appfira$lc�rrJl pemrfts fir.C_m$etas;Yarimerr.,118c art err.:)
3.Y dl hm(cheat well ruse):
30 R 35 _lo
ritf�y Tra DtA QT Ttn t�CS laAraateta._
iYtttcrSUpitla Wtdl' $a 5rUA, .010 SCH-40 PVC
DAgticulftin l 0munitipaUPtblic
fat;Jeotlmml()leatingtooling'Suppin) QResadential Water Supply(single)
01mclusoial/C'onumdal Olkesidentrnl Water Supply(shamd) FROM 'ro DIA9HRtfil; Fa�ta t+t�rraa t�ou�er
C316i lion ft. h:
Ikon-Water Supply Weft:
mMonitorivj OR4=2 .
Injection Well: _
0Agitifer Rechmp 00mundmita ftentediation
Mtluft Stomp and Amairtr QSaljnilry Barrier re xl MATERIAL waaP a,m cvr t7 t
28 R. 35 A. FILTER SAND # 2
❑AguifcaTat Llstomm'atcrvmnsge R. ft,
t]trgavimcnqaiTvAmokW, t75tdasi4cmecoamtmi
2t}:�A1tII�.3"i3r 'it^ (acii` iliiyn.SMtc#3dt
❑Geotftennal(Closed Loop) oThcer FROM 170 taBSt'R MON tam,Aff# vWr4ca #sir00
oGoodlefulal(KCfl li R@t111t3) O01h't lain under 02l Renialks) 0 ft. 20' d: FILL SILTY SAND
20' R, 35' ft. WET SILTY SAND
I.AateWell(s)Completed; 6-2-21 WdIID#Tmw-1 tf. ft: pp
Sa: ft, ft
Willis Grocery/Crossroads Pet Supplies (L tt. 1 20
Facfli1}A)%1=xmm Factilk M#(if appiicuble)
R. fi t
4025 West NC Hwy 10, Newton, NC, 28658 {},
Pk-siulmdom City.and Z p
,23zlt�itilAttlCS .
Catawba BENTONITE SEAL 26 TO 281
C:000, l}Amd td<td r1040on'No,(PIN)
5h.l;abrade and 1.6ngitadc in dcgrecsArnimatiW ceonds or decimal degas 23.Certilicmtifrn:
(ftwellbald;Out i*10 isSIMLktd) ���
>! W 5ign#it7.8- W_101 ;. �, /2021
hector
6.Is(are)the-wdl(s): OPe manent or ZTemporar} By a gttJn#drEr foCn !hrrr&}C�rrt v rJiut rhr ntlJ rJ s�x(wtirl evomwied in -ordence
i4th MA NCAC 01C:'..01M or I M KCAC 02C-.A'.Ld.J 1*11 G'onstrr Oan Sittrae aMs and rwre
7.b#ItLt a reprir"to an existing wrif; €vs or MN(► copy s{rharrworeWrbrm pmti&d to ow nil tml r.
*Alt is 0 repok fill m?bwm 4 ctd ceW arr1"Ofomvrw molt r>kpkin iron x+era+re of the 23.Site d an pr additional N eth llctttlte:
repstirand ier!?!rmat"rnrtiafa Or On At bark of 6b fVML last tit
You amy tise the back of*s pagev'provide additional well site details or well
S.Is umber of wells constituted: 1 con motion details. You may also aliaeb additional pages if necessary.
for rrndvll4el4hrrfavrov'ratan-iswersupptrwrll3 ONLY ntftdzWsamemrrsh9rt'Am,}nu.em A L � S f1
Sm0vtut fprm .►
R.Total4wdt depth below land surfam 35 (tt;) 24a. Par All WElls: SuGlro1 dus'fann within 30 date of oompletion of,Nell
Aer muflipir icylls tin 4 erprks i/dWerrm ter Wm-30-200'and 2@14V) c omstnection to the fOflom n3.
In.Static wSterlevvt below top of toising: {R,) ft•6100 of tarter Rtsgierees,InforknAtian PMftgft Tinft,
4r mint-#'Jelin&&0tv edUq,►ur"4' 1617 Mail Service Onier.Raldg6,KC 276"4617
1 t.liorrtliole dismettx:2.z s" fin) 24b.by lniectlon 3&SM ONLY:6In addition to s`etuling Ilie foam to ft addtw in
24a abol e, also tsa'bmit a copy of This lbrni,within 50 duns of completion of%roll
IL Well vollArmcdon mothad:DRIVEN eotut WOO to the 110110ivit1g: �
(Lt.m i r.-rotw,tmbi4 dhm pssh
Dlrision of Warier Rmvrm,tlndtMmund Injection Control Program,
FOR WA7l RSiiPPLY1l i.tS ONLY: 1636 MaH Service Center,Raleigb.NC 276"4636
13a YtelA fgpm) Method aftesb tie.For WatervpAj t4t,tdoCtlon\fells
Also submit one copy of this fornn within.0 days.of completion_of
13b.D utbcdon hlitt Amount well constmction to the cmmt),t ct fttt dcgavtm to of the c ounl where
Constructed.
Form GW-t Myth Gamlins tint of Emimmrm and Naur il Re wvcs--Dhi&loa ofWatet RMrtes Re%-Iwd AgpAt 201.1
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