GW1-2021-02737_Well Construction - GW1_20210512

WELL,CONSTRUCTION RECORD 'For DtomalUstONLY:
'Mh;for,n con be and for stv*ov adi"wdls
1.Well Contractor Information:
Stefan Smith FR M oFSCRtPrtt?V
A14011 Coomdar Name ft. ft.
ft. ft,
3576A
NC Well CoramclorcertifrcailonNnfbrl df'dt3tFdt. ar ni(Ft " OR; Aeabk '. '
FROM TO OWNFTRttB T! SS MATSRiAI.
SAEDACCO Inc 0 ft, 10' ft 2° in. SCH-40 PVC
Cainpm-NanK 1'6c1 Nf sOR'dttBPYC- a itAir+riS 'I Aa
FROM 122 DIAINIF I T11ICKN1W I MA1FRUt1.
2.'Wolt Constntetion Permit#: ft, fl. hL
lid ati oWfiruNr w H pe'rmirs(Le.Cmnim Smxr;Marianne.Ir#Wdcn efr.)
3.Wcll Usc(cheelcivellusc}: 7-.GREI"ft
WaterSuppb Wdl: FR M I TO V1AMFM r,ors"T' 11"00KNESS MA�TRR At;
DAgficubi ml OMunic pal/Adblic 10' ft. 25' ( 2- la. O10 SCIi-40 PVC
DGeothenual(ReatingtCooling Supply) DResiden tial Water Suppb',Wngld) ft. L in
C)industtial(Conunetrial DRtsidenitia.I Water Supply(shatod) A.tlltAtl71 ,
FROM 170 31rATL?R61.. 61ltPLACEHP�tT.MSr1tOD�AMOtA4T
Dlai. tion 0 ft. 6' ft. Portland .Pour
Non-Water Supply Well: fL
u.
®Monitori Qlttxm
1n]ectl0R Yeti:- ft. (L
DAclWzrRech;lrgt C)CiroundiimucrJtcmetli>ftion F>i iw' �feste
DAcnriferStompsodRcco%vq DSalinhyBarrier 1. m+ai �
+ iarnt u
8' R 25 ft. Sand 20/30
DAquifer Test DStonmv=r t)rmnagc
tt. ft.
DEVCtimcntal T=bnolou DSubsidacc Control
i;AR O.1i0t1.•tla64ddi ie,iii7;ketfsf°
DGeothennal(Closed loop) Wen= "FROM D.Rsett nos ,.e..arn roltlnicti n euo Vie)
DGeothetnaal(ReatingCooliM Retunr) 130diec(tMain under 021 Rentals) 0 M 71 ft. Sand
7' (t, 15' A. Clay
4.DateWen($)Conlpleted: 4-6-21 Wd1ID#BMW2 15' It. 25' (t, Silty sand to son ?9
5a.Weir lticathtn It. fu
Trimble Plant Road Property fi, ft MAY a �Q
Fac17FtylO =Name Fmility MOOrapptjMblc) R, G.
175 Yadkin Rd., Southern Pines, NC, 283870. p,
PhysW Addmss City.rindZip 2t._ 1 At KS
Moore 2 foot bentonite seal from 6 to 8 feet.
Caofny Pared Ide(dirkationNo,(1Tf )
5b.latitude and t ongitude in degreesafminates/seconds or decimal dt s: i}-ncatioa:
(tt vivIl tktd;o1k latllot*is sldfliko)
35.190436 N° 79.379372 W 4/21/2021
SiSml of Cc: Weu Coili�mr � llaac
6.Is[arc}the well(s): rY4Pcrmanent or 377 empornr}'. H)'Aigni-A this farm)hdrby ee i*rh{i f a..tiwlw was(wtlir)a masxnreted hr&-voAfmce
si4A f M NCAC 02C.(ff lid or 134 NCAC Ok,amn wet!Calutmcedly Smnkrds 4nd Ow a
7.ls this a repair toan editing ndl: oYts or MNn �alrolrhurnmr►�srir�t�+v1'hfndmiar.ro()m��r.
lffhlx)x rf repatr,,Ji�l+�i�ro�ef well cro+asfnmrfon i.+r,�rmaxAnn and F.eptatN rke rxrrkre r�rhr
reptira nder321 rrmarks srreim9 or on dew brut of'ddi farce 23.St"diagram 0r additional H ell detall:.
You lacy use the back,of this page to provide additional avil-site details or well
8.Numberof wells constructed: 1 constmetiondetails. You moy'also Attach additional pages if necessary.
Forma+fiV,eInjeeximiormrtin-#crier Apply w(h ONLY n+lththtavmesonstracrfon,yewcan stlRA1I7'[A1LII�CTf1CT713N$
subwe doe fore
9.Total well depth below land surface: 25 (ft) 24s. For Aft Well 'Submit this form tvid"30 days of oot Tkdon of well
FnrnwhWe wells fist oll depths(f diPre lts(ertemvie-MW oral2@1W) eonstntction to the follt whir,
10.Static water:level below top of"sing: (ft.) Division of Water Re%6uftts,lofnnuation Pmcessing Unit,
if xwu r Mild It of a1Y Cd&1 g W"+" 16171Mail Ser iec Obiter,Raleigh,NC 276"4617
I
t i.Borelrnlc diameter.6 5° (ia) 24b.F1�rr[d on Wells Ohil Y:r In addition to sending the fomt to the aM=in
24aabose. also unit a copy of;this forrn within 10 days of completion of well
IL Wdl:consmrction method: Sonic const lion to the following:
(i.e.mWr.:warp.cable difed fwk cw.i I
Dt islon of Water Resources;Underground Injection Control Program,
FOR WATER SGTPLY'UUA S ONLY: 1636 Man Service Venter,Rnlelgh NC 27649.1636
till 1!ield(gum) Method of tt t tic.For Water SoUIs br injacttote Welb:
Also submit otle copy of this fonn S nithin 30 days of completion of
13b.Disinfection type: Amnunt: moll consiniction to the cutmt4 hcRhh deptAmait of the count}where
constructcd,
FntmGN t NonhcavolinsDzPnuirmufEmiian=dWdNfinuslltcsomocs—Di�islosofA'afrrREsoiro5:. Re%-bcdAL%USt3013