GW1-2021-05697_Well Construction - GW1_20210727

WELL CONSTRUCTION RECORD For letenml UscONLY:
This form can be used ft sinle or maniple wells
1.Well Contractor Information:
11C WATBA NIC
Brian Ewing rROM, )O 1 DrS- IVNIONi
well Contraaor Name
4240-B
d.L i)t]i Fdt Tl+lti= aierPiuhi iastvl?rt Ell :OR'LTIYFR if`. . OcaD
NC Well CordrattorCeriiGcation Nmnbcr PROM To PiAmrmw TnICh'NESi MATERIAL.
SAEDACCO Inc (L n. hL
Neatly Norm sB: NNPR'C�t<tN 08? 7NC. 46t►rirw>tt a ruAAoe
PROM 1 TO OLf1IMR TIRM'ESS MAIMRIA
2.Well Construction Permit#: R. tt
list atl applinible urnpe"Wh(ie.Gamer,Stair.Variance,lt} fftlt sir.7
kL
3.Well Use(cbcck well use): a. ScRIi�N 1 ,
WaterSuppty Well: PROM TO 01A11tT1:R S.OT617F. TttrcTcarssI MATMUAL
OAgrkultural DMunicipall ttblic 65 ft. 70 n. 1 In. -001 STAINLESS STEEL
OCreothemtal(HeatingACooling Supply) OlkesidertU Water Supply(single) & (L
OlndtratriaUCommeicial DResidontial Writer Supplyfsllamd) iN 4iR0
FROM I TO MATERUL 011PIACTMEW MMOD&AMOUNT
011nigiflion ft. fr.
Non-Water SupplyWcit: (L k
DMonitorigg oRccovery
Injection Well: n. (L i
OAgllifer Recharge OCiroundmicr RemciliAt on 19i SiANDlGlt7L P d ;erta
OAquft Storage and Rcco%viy asalinily Harrier FROM MATP,Rrwr RMPi A LL irr�TMITN01)
n. a:
❑Aquifer Test ❑5tortmsatcr Drainage
OExrcnmcntaI'Tcchnotog OSt"dcncc Control
70.:DRi1,IdiYti.i�OG'
❑C,eothemml(Closed Loop) oTraeee FROM I To DrSCRTMON gogr,k1rom rowmck t*
aGeolhetnml(H 11. Return) O0thet(yokin under#2t Renlafk3) 0 ft. 15 (L FILL SILTY SAND
15 fL 20 ft. SAME
4.Date Weil(s)Completed: 6-28-21 Wd)IDAC;W-1 20 (1. 30 rL SILTY SAND CLAY
Ss.Well Latatlnn: 30 (L 40 (L SILTY SAND MOIST TO WET
40 (L 50 r4 SAME 1. �
Facility0o,wrNorm Facility IDlr(ifapp5cabk) 50 tt. 70 ft. MICA PWR
7110 Sandy Forks Road Raleigh, NC 27609 crake Count,--, n- n.
Phrsisel Addm n City.and Zip 21
WATER SAMPLE tf/SP-22
C.aaah PArcet idnq Goatioa io,(PIN) 11�;,tl�: �e�
sh.IAtitpde and Terigitude In degreedmimitc0scc6nds or declma)degrees: 22.Certification:
(1tsselt(Acid.am(atJattac is sui('i.*t0.)
w —Brian.-Ew.i.n 6/30/2021
6idruttm orcet"Wil Weil Canuactar '��- Date
6.Is(arc)the w'ell(s): OPermanent or Temporary Al xfgilirig A b form I twebt,crrl char Aw wv-14sI mar fowerl carim red tit aee6rdimer
+vflh!3A NGAC A3C.(140t�nr I,fA NCAG;(Y_'C AIO(1 R`ep CaxsirnHYJan Srew(arda aiuJ disk a
7.Ls this a repair to an existing well: Mee or ENn .spy aJrh21►rty niAna barn pru�iikd rr,thr sirll akmir..
I/M(r It n repair,jilt out kwmn will rantrtrn Bern lnf6miatian and exe4in rhr_nanare of fir
repair andera21 rmwrarlrrserAm or an thr bark ref this farm. 23.Site diagrRm or additional well dmflgA
You nwy use the ba&of this page to prm•ide additional well site details or well
8.Number of wells constructed: 1 constmWon deceits. You tnav also attach additional pages if tmcessary.
Farmutrlrrfr tttjrcrlbn ar nrxr-nmrer stgfplr xr(b ONLY ti0i the anise erNrshvrrAw,ymM" SL"tRMTiTA INS7(IGTIONR
sxUmir arxe Arturo. -
9.Total'a'ell depth below,land surface: 70 (R•) 24a. Por AU Weller Submit this.form within 30 days of campMion of nrll
For MAJIdVir Wells lift nli hPt(ra(fdo'erenr(erangilr .I@ I(Kr'and IfW) construction to the rfotl€rn ng;
10.Static water level below top of easingr (R.) Division of Water Re'sourt:es.Information Pmmsinp'tlnit.
Ijv.nArr level h d6fttle cdatfljr,,OR"+" 1611 Mail,Scrvicc Ctutcr,Ralcig)t,PVC 216"4617
11.Mrdrok diameter:2.25 fin) 24b.For Inicedon V_a ONLY: In addition to sending the form to the address in
24aabme. also submit a oaW of this form within 30 days of completion of well
12.Well constMetlon method: DRIVEN construction to the follm ijW j
(i.e.au0er.ratarg,cable direct posh etc.) Division of Water PAwarees,Underpround Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Afatl Service Center.Ralt.10.N. C 27699.1636
i
13a,Vidd(gpm) Method of test: 24c.For Water Spue&&iniactkrn Wells:
Also submit one cop}of this form':%►ithrn 30 days of completion of
13b.Disinfectiont)pe�- p „- Amount: well construction to the county health"department of the cotuuy where
constructed,
FormGW-t Noah Carolina Dqurbacm of Emimnnrnl aid Nana)ltcsowmi-Dhislonoflisw Resources, Aesltsed A*02013