GW1-2021-01610_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD FortKctnNUsctJNLY;
111ts form con be Used[ef ftknr ad4ic nrtls i
1.Well Contmoor.Intormation:
Stefan Smith YR M TO_ ORS IMON
�1't11Cpiflstacto*Name V m ft. It.
3576A
NCGtrollGummctorCertiffiMionNwnber APn :� 2021 ts.ot e.r ll�axrrtiaahl tMeq ox�r �
FROM rU DIAI.%WTFR . TII1Ct:igFM I MATERIAL
SAEDACCO Inc ��� -;f 9)�i111i 0 (L 4' fL 2° 1 1e, SCH-40 PVC
CoovinyNaelr as ��y1R 0f+0i1 16.;1!"
FROM iTO BLAMR I TIl(Cla'ti~S,S MATERIAL
2.Well Constractinn Pecmh>r: ft. ft. t++
list ala applimme wrNprnnW fit'.County.State,Variawe,Irta!em eir.)
3.Well.Usc(enter well aso. 17:.
Water Supply Wdl: VROM Tt) PIAMRTVR 1,61.0TOF TolCKNI SS MATMIAL
DAg(icultural QMunicipal/PubliC 4' 0. 19' ft. 21 In ; 010 SCH-40 PVC
OGeothemlal(HeatingtCaoling Supply) l7Residettiai Water Supply(single) ft. ft to
ObidustriallComnnrciai DResidential Water Supply(shared) tt<3Rt)t37
Fi10M MATERUL EAVLACSMENTAWMOD&AMOUNT'
01higation 0 ft. 2' it, Portland Pour
Non-Water Supply Well:
®R+lartitorin C]};eCo� ' A=
Injection Well:
OAquifaRechmp MruundvmtcrRcinediattion
ra M MATfiRRAt. YM�tA It�vrMRTf( n
OAquifer Stmxgc old Recamy OSalinity Raniei 3' tL 19' ft. Sand 2
DAquifer Test ❑ m'St Stomter VMiMge
it. ft.
Mllcrimcatal Tcchn tog 13Subsidence Control
O:.DRtl3.lPtti''EiU[#�i>srli�}tlHlontl�ahcrlslfliteCee�lt
OGeotnemml(Close loop) DRacet• PROM To DFscRtt'Ttor co»r kerdne+l ae8'rock fl t eed
❑Gentitfmtal(Hea' ACo • Return) OOtber Wqgain under#2l Renaft 0 ft. 7' it. Sand
7' R. 11' tL Clayey sand
4.Date Well(�)Completed, 4-4-21 WellIDttMW2 11' (1. 14' (L Cemented sandy silt
52.Well Ltleatlnn: 14' (L 191 It; Sandy 'silt
Former Circle R n. IL
Fakir)DmwrNam Faci yiDstitaepplicsble) p, ft,
3000 Jefferson Davis Hwy, Sanford, NC, 27332 h. ft.
I%v;W Addrrss.C.W.and Zip 3ls ttti,MA
Lee 1 foot bentonite seal from 2 to 3 feet.
Cache Pticidlttri}PieiltiauTl4.{t'IA1)
Sb.Llititude and Ungttudc in mUmtes/wrinds or decimal degrew. 2L Certillwation:
(if welt too("41200og19 sldficiera)
35.416651 N 79.229389 W _ 3/19/2021
Si- >1 Weli Ceiltsaelar Data
6.is(are)the retl(s): >oPenrument or 17Temporary by slgtrns dut,farmm 1 hereby rrMfy-that do well/s1 kmr t W)ew m and in a vordm tr
Wtb I5A NC_AC MAIM o.15A NCAC 42C,AZ00 Well ConstrorW n SmadmAs and that a
7.Is this a repair toan existing well: Mts or MNt► tq�safth€r►rcaprltinslr�rnpsmvtkdtoAutn-!t<moicr,
Jf thls Ito tepm'r.,flll oWAamm a r7J ganitrurrton lnfnrcaatlon a+rd r kidil Ow naw'-r f d it
repairan*trrd?1 nmatks arrtuxr ar on du burl:of this forac 23.Site ditrgt'arn"or additional well details:
You may use the back of this page to OrgAide additional meil site details or well
S.Nunmberof»cilseorsttveted: 1 collsuuctiondetails. You"may also attach additiotal'pagiesifeecessen•.
Fru xraMr*1 hrjerrsoal or owm-AaierslTpfr wefts ONi.1 WrA.*font constasR 4m.3R*em
submft'wfam
SuBMMALMSTUCTIONS
9.Total well depth below land surface: 19 00 24R. Pnr All tVellc: Stibtidt this'forin within 30 days of cotnpletion of mill
For nsuJA$f wells disc all BFprAt(f deji'e► ll(eTMVe-3@ZM*oud 010T) construction to the foltorning
10.Stntie water lmt4 below tap of casitlgA 7 (k) 111t islon of Watt:r Resources.lnfortnbtion ProeessiDg Unit,
df ebter dPvrl h atrot r edtlnS ux"#" t617 Mail Setviee Center,Rale*h,WC 27699-1617
11.Romhnte diameter:8.25° (in,) 24b.Fnr inhW0 WaEc 4DNLY: In,addition to sending the fomi to the address in
24aatbove.also sitbinit a copy of "his fume within 10 dais of completion of well
12.Well enstraetim inethild:BSA tO1LSttlueliCn tb the foAotiviag
(ia saw.rotor).cabfa direct push ckc)
Dh'ision of Water Resources,Underground Injection Control Pregram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mill Service Center,Ralelptl.NC 216"4636
13s.Vidd(gpm) Metbod of test: 24c.For WaterSaDDW&Injection'Welts:
.Also submit one cop}°of this fo(di MIhin 30 days of eolupletion of
13b.Disinfactinn Type Amount: wet)construction to the county hcAlth depart'rueffAL of ft C0014y where
constmmd,
Form GW-t North Camllns Dgxnt nt flf Fm1rDt=M and l aMW Rcsaurms-Di hkn cM'alcr Rewirm ReOwd Atilg A 2013