GW1-2021-03987_Well Construction - GW1_20210721

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WELL CONSTRUMON RECORD �S liar lw mluscony:
'this fir can be used far sftle o`multipk wells ✓�.,
1.Well Ontractorinformatlon: \J
n A3�lt;
Brian Ewing t, 0 M TO opsmir"0114
N'eltCorltsWVNAM 4y�'r R, ft.
4240-8 '� ; 202� R
NC:We)IComworCOdif w1oaNnmbct ..�L KOUTI CASIN.G arir►+YHi4*W*t ' irwiTMA
*? r gg51Cl�Valli FROM 70 I IAMFTFtt WWA N MATERIAL
SAEDACCO Inc r ,3t��i CCw 0 ft. 18 fu 2 ie. SCH 40 PVC
Naruc ars`4e° e19C
Campuatl
FROM To I DIAAiETBR I 7HKI.NTM ^' I MAUIUAL
2.Wdl Ctln..tmcxion Permit 9f: R, tt to
Lim (Le.Cmrnry.Sean,Variwerr,l*C601 r#%)
A. ft. tar
3.Wcil Use(cha*wcll nee): , w
WaterSOp(ilp WCll: FROM TO DIAMR!MR SIA T811W: I TNIC"IESS I MATURipr,.
DAgIiCulttilal L7MntliCipalll'ublir 18 R. 33 R, 2" ib 010 SCH 40 PVC
Meothemul(Henthotootiog Supply) ®Residential Water Supply(single) R' '
aindusuiia)fC,onimmial DResidentiai Water Supply(sbamd) all iRO t:
FROM ITO kLL%ftRW. ENFLt i tAWMOD&AM URT
131niaNtion 0 R. 14 R.. PORTLAND POURED
Non-water Supply Well.
mmonitorin C]It otic
Injection Well: R. IL
QAglrifct Rcrharge Wroundw alcr itemedlation 99.,�5 -
O ifcrSi A11d RtC C)Sali llaaiCr -FROM 1ATRR r. PAP),,_ , #- Mr rnnD
oraS Otlal � 16 R. 33 R. FILTER SAND # 2
❑Atluifcr 7cst f3 itommatcr"thttirlrtge
R, ft.
0Expclialcntnt 7'cchnolea 0subsidmcc Control
�1::DRtlil,al�fi= (1�'a�i'ifEA'SiBiN '`sst`a�cexta
OGeothemml(Closet Loop) DTracer FROM 1 71) DltscRrrnON 001W.604 w3wrock lypt.00b abn,W-1
DGsotllemnli(Reati Renim) n0tber(acylain under 421 Rematlas) 0 R. 5' IL FILL SILTY SAND
5' (L 10' it, SILTY!SAND
4."ate We1►(s)Gbnlpleted: 6-25-21 Wd)IDAMN-02 10
' fi, 33' R. SILTY!SAND CLAY MOIST TO WET
St.W411 t.AHAtinD: (L ft.
Pilot Travel Center R. (1.
Fac17it)M'MTxMW Facility WX01'appliesble)
1006 Charlotte Hwy., Troutman, NC, 28166
Pktkel Addme.City.and Zip :dl ttCB
Iredell BENTONITE SEAL 14 TO 16'
Courtly Pareei,tdcnufialriooNn:fpxN)
Sb.11400ide'alnd Ungtmde is degreahnimttestsecondsor decimal degrees. 22.CeHifrcabina:
6twett fietd,(UrtiaUlory Is sidfltkid) ',!
N W B '� ,11r.EW�i1 „�,�.,.��, 6/30/2021
Sipmx Oren lfrcd Weil Corluaclar Dau
6.Is(are)the weil(s): OPermenent or n7'emporary Or*s&g,hs f„m I tend,,,eergfy this,rlr wdki)war 4 r&.)emwmaed in&vwdmee
%, A 15A NCAC 02C OM or I JA NCAC Ok.0300 Kell Cvn0mWen Smndmrlt and thsrt o
7.16,this a repstrto an existing well: nYei or MNo C4rF{1}fAAlKcanlhnSbertaArT1•ldcdmilir.art10~r,
f/thlrle r+rrprtlr.Jlll aal.krra w�seal commedma the nnrkre offhe
rYpciramirr621 rnnrarkx x�ti7rxrr ar-nn rhr hdrt ili(s/mac 23.Site d1a'1,t'om or additional well detoitc:
You may use die l of this page`,to praidle addidofWl wdl site detaiis or well
S.Nutnberetwelts constnided: 1 eanstmedon details. You aW also hooch additional pages if necessary.
f m rlon of novt•n mi+ulpppJr weAs ONLY 0hsub"Lft ow form -rlu ezrnrc uorrsdwrtton.yew ca+r CCTR1►fCl TAt'INSR fJG'f70NC
9.Total wdl depth before kind surface: 33 (il,) 2Aa Por All Wells: Submit this faun uAlAn 30 drays of comptedon of veil
fnrarvrrfrlFlRneflsliftfrfi rhrifdekrKnt.(ertriPaptr J 3(llJ'mid3�.1fJ11} con5trudionto tic fettonins
10.Stftle water level below top of casing: M) flixislon of Water ResdOrem Iaformatiau Pmcraft Unit,
1/1Wttt area hdbotV MibM wa"+" 1617 MO St?niee Centex.Raleipfi,NC'2760-1617
11.Darehote distneter:8.25" (in,) 24b.&CJUMoon Wells ONLY:i In addition to ser-Ong the form to the Wilms in
24aAm'e. also Mraii-a copy of[tI{s form n-itliin 30 dayi of completion of Util
?2.`�'Cll canstrn¢tion Method,BORED conmelion to the rbllowiw
(f e.MISM.nlrer}.tabie.dut0 pasta.cic)
Di1981011 of Water'ResonremUndergPoond Injection Control Program,
FOR WATE SUPPLY W1;L[S ONLY: 1636114A See►ice(tinter,Raleigh,NC 276994636
13a l dd(gpm) Method of test 24c.For WahxSag&&tpJoK M VVclts
Also submit one copy of this fonn mithm 30'fts of completion of
13b.:][Wafeptinn type- Amount• well constnaction to the colrnh health dep nMent of the county ah=
eo cted.
Drpgliurrnt r Rcn'isedAA4Ust2013
ForaaGlV1 Not1hC'amlins af�3romnclpmd'ta[uralRosowocs-l3hislonof�laicrft�Ir�
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