GW1-2021-02738_Well Construction - GW1_20210512

WELL CONSTRUCTION RECORD For Ir erm)VwONLY:
Thh form ion be used,for slVc or ntu fqk nos
1.Well Gintractor.lnfortnatlom
Stefan Smith rR M APSP1ttFTTt)V
t8141 C01019aa Name 0. ft. `
ft. ft.
3576A
WCIVdIICoramciorOmirkwionNnnter lS.Og7RRfi fl�(3 nririiitlf�asn} Af►t/R;,11!ti;R iicrbk
PROM. TO DTA1%1FTritR VFM 74ATLRTAI.
SABDACCO Inc 0 h, 6 ft 2- In. SCE-40 PVC
Coatctnx Ptanye T6:1 CA ii1t;; R 27F$1NG= t►rrutst''Inset 1
FROM
7T1 D[A11P. r1TICKt1F5S 1NAlfRIAL
2.**VdI Cilnstraction Permit#: 1t. tt, ia:
last all appli-mr,writ permits fir.Cmmty,State,Yadawe,lgbwc l rtr.)
ft. tf. ln.
3.Wdl Use(eht ckwell arc): a
Water Supply Wd): VRoM TT7 01Ae1P»:a 1 STAT611Z I T111. P.S9 MATPRTAT;
OAgticaltntai i,MttlticipallPabGe 61 'R. 16' h. 2° in 010 SCx-40 PVC
OGrothermal(Heatingtooi ft Supply) i pwi'dentunl Warr supply(single)
ClIndwatVOornmerdal OResidential Water Stipply(shared) iAFt7ROtIT ;;
TROM TO TlATERTAL gTPLAC _-vAiMOD&"oU"
Oltti (fGTri 0 ft. 3' fie Portland Pour
Non-Water Supply Well: (L rL
�Monitotin []I2€cov
Injection Welt: ft- (L
CJAgnrfcr)Zecfi9tgc L1GnalTtdn-aterltctltcdiation 9_ ° A
eqTO I MATORIA1. w; tT► � n
DAgnifcr Storage and Recovrry psalinity Bahrier 31 R, 16- ft, Sand 20/30
DAgnifcrTtst OstommatrrDraintage
OExpeTimcntnITvahnotogy ❑StlbsidcaccContro!
2t1.=tlRff�.7rttl xt3Ct'rtii�cl�ddti?endt s;heidstfinect�
OGeothwwl(Closed Loop) PTO= FROM 170 OFSCRW"ON COw'.11 SnWrurk WK,youtee"m
pGoot heal if 1Coati ltetum) I70thet( iaiNvrtder#2t Reroatlls) ° tt. 7� to. Sand
7' fL 16' fL. Silty'sand to sand
4.Date Well(s)Completed: 4-7-21 Well]DO BMrt3 fL
54 WCH l:ttcaOM: (L IL {�
Trimble Plant Road Property ti. fl. ��H V �+
1W11fly;M=x81W rwbw IDN OrapptkAle) n. ft. , I,i
r r�S��
175 Yadkin Rd., Southern Pines, NC, 28387 R. (L 63.r i '
lyla}�7colRddmss Cit}.s�tFdZi(1 •21.R i1S s,
R
Moore 2 foot bentonite seal from 3 to 5 feet.
t"vol,; P*Mdhuldromoolk1V0.(PIN)
Sh.latitude and Longitude in degreestavinutics/almtinds or decimal degre r 22 tiettiftcation:
atnttt Add,caw Iaft r%isstdlWttu)
35.190996 N 79.379827 W 4/21/2021
SigaeTl of Wets Cotmnctor Orate
6.Is(nee)the vvtt)(S): ZTe mantnt or OTemporary_ fib 14mins chit fbrm 1 herieO ev-16 Thal thr u r11 fr)rrs fowor)nona nwM ter attwMmtte
a h*13A NCAC 02C,0100 or 114 NCAC Q.rC,fi2W III-tl Como+-dctR Stanlartlrontlshal d
7.Lti tbig 8 repilir ttr an Cxi4tittg r'ell: 0110 or MNo cot-r of far'nWord has bOmpmv k4 M-4hr nv-M user,
tf thtx 1T tt tvprttr.�d rat kntnrw uetl eaast+ucritm dtrfaneetk+++and rxptatn tfir nnrar�rf rhr '
iv*r anderP?1 nernarksj*via►e or raw the bait pf thb farm. 23.Site dlltgram or additional well detatk
You may,we the back of this Rage to pratide additional well site details or well
8.Namber ofWelis eonstr cued: 1 construction details. You tnay also attacb additional po*if tmemrv.
Fnrmahi,Rhin/erlWOfnrm•lswerW)u!v'W41 ONLY"M rite
x►nrecnnspwctlon.youra� s ON
subolif owe forts, i113Af1'C1Ai_ e)MU&I C
9.TotaSwelt depth betotr land suyfaw 16 (It;) 24s. Por AU Wells: Subndt M form a3thin 30 dzys of completion of aril
fnrnee�itirteuatisllttriAdrluAtljcl rtartee[nriytr3 2Ad7`d ?k�lt7d1) cmStmetionto the follouing:
10.Stack water Intl belay top of easing: fly,) Wivislon of Water Rtsources.Information Processing Unit.
1f v.vuur lever lsetin T Caning.ax"+" 1617 Mah Senice Ci`t ter.9116glt,lVC 276"460
11.13otcholc diameter:6.5° (in..) 24b. i1,�►t4]jy ONL Y: In addition to sending dte form to ft address in
24a above. also submit a:copy of this forth within 10 days of completion of+vOl
12.Well coosttrnetton nMbod: Sonic ejottstmelion to the fiUovvirtg;
;i&mtga rotarp:cablG d4v61 push etc:l Dh1sion of Water Resou mv.%,Underground Injection Control Program,
FOR WATER Si}PPLY'%Tl,LS ONLY: 1636 AM Service Colter,RsieWi.NC 376994636
13a Vicki(gpm) Method of test2,4c.-For Water So MIX&fpjmtl iu l'eft
Alm submit one cop} of this fohn'AAtbin 30 ft s of con*"of
13b.Disinfection type Amount vvcli construction to the co,mly l`c hh depamtxnrt of the county`where
congnactod. I
Form GW-t Noah Carotitet IkMm n ml of l ndronment anti Namual Resourms-Dkvislon oMIstrr .Resources Raised A 20 i 3