GW1-2021-02605_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD For lrtsmnl Use ONLY:
This form coo be used ror single or mW tipk%mgs
t.Well Contractor infottnatton:
• �� a.H'AI�t.iAN
Dylan Fierst FR M O CRIP't1ON
YMI cof t oorNAM � � > ft. ft.
FV„ .
4507-A •f��r'r'mCe_ 'ill
NCWcflCoramorCcniflemionNrudmcr �• G y v0y�,0'll MtYTF.Rt SliaT3 oriii>ti8i I Ton �t ttCr �sss ATERIAL
SAEDACCO Inc 0 tL 3.5 tL 1° 1a. SCH-40 PVC
Gbntpnay It#me tb. , N OIt INC tel: d#oo
FROM DUAIFTER I TInCfOVM IMAlER1AL
2.14'd)Conomcdon Permit#:
Uit all aW1rnNe tectlprMWts fcr.Caunrv,.Smrr;Variatwo,Trifil:vt or.)
3.Wdl lisc(check.wellrrce): t7 SC
Water Supply Well- FRdM TOI Di IF"R 11 Sr TSUZ TrrmCl M, MATMUAr,
DAgriculttiTet GitVlOnicipalfAlbiiC 3.51(t. 13.5 0. 1" lg .010 SCH-40 PVC Pre-Pick
C)Gwtfxfml(Reatigg/Cooling Supply) OResidenrml Water&i"ly(single) it. ft. In
QlndustrioUComtnereial OResideutitl Water Supply(slmrad) I CiptOT>'t _
FROM TO MAmFRIAL EbTPtACVd9NT MrMOD A:AMOLM
Dni tion tt.
Non-Water Supply Well:
mmorritoriap
Q12cco�m ft.. tt.
injection ell:
C7Agmtifer Rcchatg£ Qt'lmtirdmrnter ltcmodiatian ;
imquifcr:Stomgc and Recomlemy E3,%Iinity"131miel Fa4 70 tAT1 RrAt. ACTAr i n
1.5' (L 13.5' ft. FILTER SAND #2
❑AgrMer T'cst QStOmmzttcr Drainage
(L
DEVcrimcntat T=JmotM Q$dbsidcnce CorArol A;
2liKttRlIrI3A't's ,aii{I18a»til aAi6f :i�ceesti
OGeoilxrutal(Closed Loop) OTraax :FROM TO D cRitrnOr callr;MAran ru 'ntek n He
DGeoUgtnmai e8liti Gfoli Return) o0dw rounder#21 Reruads) 0 ft. 13.5' fL Sand
ft. %
4.%tewel((3)Contpleted: 3/10/21 WdllDdTWI
A. rr.
So.Well Laeationi (L (t.
UPS Customer Center 0. tL
Facdity,OA- cr Noma FscAity TAN of Wplie6i0
2815 Carolina Beach Rd, Wilmington, NC, 28412 n. M
PksicnfAddmtdS Cimy,andZip
New Hanover Temporary well
Caoitty PAMO tdrrtli CA11on No.(PIN)
Sb,l.atltbdc and 1,•6nOwde in degrsestmitruicstsc Inds or decimal degrocs. 22.Cer4ifrcation:
(if"Vil Gold,(At 1tt 10fts is gidtlCkm)
l� W 3/22/2021
5ig�rs of Citifwd R�cD Con#rSemr � Dire
6.is('dre)the wvl1(O: t Pern►anent or ZTempor sty �j, }„ ,(yfr fcmr.f trrnb++ rrl rJiur rhr wrllj3l wwas.{�r,rl Earn urrrd rye act�3rdm rr
u,hh 7,54 MCACO2C.0100 or l5A)VCAC f 2C,0200 i1'etl Con,omWon Sm r4ards end 4rerr o
7,is this a repair to*n CXisting well: OYes or mNo cq r qf(l,4 word h"brm per pkkd ro thr xrtf suer r.
t/tAta fs a rrmrir./ffl4wt knrran uefJ saatrrurrFmr igfarmatlon and rxpfads for»arMrr of rhtt
rr,�clrnndrri3l rcrnxrkx rexi6on er ttu burs gjtMs fDrrn 23.Site diagram or:additional well detaitc:
You may use die back of this page to pmAd a additional we'll site details or well
&Nnmbtr of we(Is constrneted: 1 construction details: You M4 also 11ltach additional pages ff Decessaty.
F xWfWwr M�r l?j rM redm Or can-v�rr►ugiiph'u e#s ONLY ntrh.A-mmc conchnrcrtan,+au*wn 511�XMLTNSTuc7"iON$
9.Totai well depth below land sorfaee: 13.5 (n,) 24a. Por A Webs: Submit this form within 30 dn)s of aomp)efion of well
FormuloiplewIlsdiscandrp i(jditrrrnreexi vmple-30200'aad2EP](W) Constnrctionto the;following:
10.Static:water Inn below top of rasing: (ft) Division of Water Retourees,tofotmatiion.Pro Ice ing Unit,
1617 Mail Ser rice COter.Rid ' ,N
l�nwtrrt�+urftsoLavrcvratriN,eve"#" ergh. C29699-1o1T
1i.Borehnte diameter 2.25 (in) 24b.For inteetton MLdh ONLY:: In addition to sending the form to the addressin
24aab6te, also submit a copy of,this ibtm within 36 days of completion of meil
t2.W¢tl constm!l COO method:DRIVEN oonstrucdonto the follouing:
(i.e.anpa:.kary.d6lt dirwgAIL ex.)
Dhisloa of WaterRmonces Underground Injectlan Control Program,
FOR WATER SbTPLV Vt'F.L[S ONLY: 1636 Mail Service Center.RnWOI NC 27649-1636
Ux Vidd(Rpm) Method of test: 24c.For Water SOUIX&tnOctfon Wcits:
Also submit one cop) of'thms fonn',witbin 30 dWsofconipletionof
13b.Disinftttion type Amount: well construction to the comity health depx rtmcut of the coinq nherc
constmcted, I
Form oW>t Noith Camtina DqxftWefEmimnmcN and MnuW Resommecs—Dhislon of Urslcr Resoum RrOmd ALCU2 2013