GW1-2021-04178_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD For Immal Use ONLY:
•itchformconbeuxdfixsin*o+rnoiltiple»ells
i.Weil Contractor information:
Rich Leaaire pe+ MI T P t OY
v11401CorrtmotoTName
2593A 1S.OUM tl ornnitfi�wM1*0 4RLim, a1 licab
r.
NC Well ConmatorCenifimionNarrber O� G�
✓ FROM To DiA51ETFAt T!"MMM MATERIAL
SAEDACCO Inc ��ryL` Q� 0 fL 3 fL 2° in. SCH-40 PVC
CaaV.".Nami .•1 , N OR a3281N ►i eetilel6t eda
iROtn TO DtAAIrm Tfnt7.TRSS MAIMAL
2.Wdl Construction Pcrmft 8: ft. ft. Iin.
fiNaft dwfirnwe wr"Pem fh fL!r•County,$tar,Lhrfoerr.llfta rt stria
n. n, lln..
3.We IVUse(chcdtwdl use): zry S N
Water Supply Well: m1n.
TO =01AMRThR st T f2Z Tt1lf�MS MATT:itAT.
OAgficultmal Oh tT1cipal/PubliC 13 (r. 2° In j .010 SCH-40 PVC
OGeothennai(Heatirotooling Supply) ORmid ential Water Suppb-(single) IL in
DindDstrialtConintetrial OResidentiai Water SiIpply(stntmd) iA GROtY>
TteOM TD tITATA3RtAI. CEMI�'rMR1r/ODAtAMOIA�T
[3 lion
Non-WaterSupply'Well: (L M
mmonitod E31tecoirg
7njectloll Well:
0A4vifer lIccl mSe 00mundhnter Rcmedistion s,S t) XC1..:
Tilt TAT1 7tT- tB TAt, P- . / Mfn
OA�eTifCr.�!( A6CatidRex¢1Try G]$a9linity.l3MCI 3 M 13 A. SAND #2
0AtltriferTcs1 OStogionn ert)minagc
ft. ft.
0kxpctimentalTcchnotM ❑obsideoccCon"I
70.1)RIt:G1I t�' t'r eat �tldiiiat►tff s1f,""" n' _ „
l3Geothennal(Closed Loop) OTraoer TRO;rt TO DMCRTMO%cokes,wren foa'tca Ot.dr:
0t.teotitemial(Hea. Coo' Return) ❑0dw lain under1121 Reroaft 0 fe. 13, ft. RED CLAY SILT
fL ft.
4.Date WeU(s)Completed., 6-29-2021 WdIID#TMTt-3 fT, tt
52.Well LACAtinn: (L ry,
YADKINVILLE REFUSE DISPOSAL SITS ft. ft,
Facility/owwwame Fmuityivoarapptiarltlo) fL ft.
707 Tennessee St., YADKINVILLE, NC, 27055 h,
PJ0,s l.Addm m Cfty.and Zip 31a1tl(t
YADKIN BENTONITE FROM 0'TO 31.
Crmceiy, PArtel No,(M)
ft.lattfrhtde and Longitude indegrem0ninutskMeondsor decimal dt . 2LCeztification:
(Nxc1t tictA,air Tatnorg ts.sOfe:ken)
`-- y
e�i _ +'4 td_1 (^. 7/4/2021
5igmtam of Cat c ell Cantmctor Date
6.b(ere)the well(6): OPcimaneut or ZTemporary BV sdgnmg Ait form,.I kr re,by emir 7fiDI rkr uafljirl met f wrn'1 CantYnretrrf in ararrdvrtrr
with IM NCAC 02C.01M or MA MCAC 07C,020D IWO Co#0rmV m Stam*wda and hat a
7.is this a repair to on m dsting well: oW s or M-No tops o}Fiat rrrn.ar t n�t ,T,�r,�'&le�fi In d+r M,�t(M ref.
tf drts Ito repdn JAl out o ud1 roFmnmt m lnfomTarinn and e.Wfah the normfe of mt
repair rm,frr 421 trmarb srdim or m tar bark of this farm. 23.Site diagram or edditional well details:
You play use the bus-,of dos pageto,pm*.ide add9domi Well site details or weil
S.Numberof si'ells constructed: 1 cbnstmetion details. You may also cinch additional pages if necessary.
Formaldpfr Injection or NMI-4meeAwplyWell ONLY nithdmremrrerrshnctlott,}r+u J ij
rmW t mW faun St]BMAi,lticq $
9.Totali eltdepth below land surrace: 13 {R.) 24s. For All Wells: Sibinit thiS;Ioun within 30 dins of oonipladlon of well
Fortmnfd;lk imfls tlsrall,depda edifferem knmptr-1d?+20fi`asuf 61w) CKmSttitcti4n to the(Arcing;
Ili.Stotle water ie►'el below top of easing s (it.) Division of Water Resa frees,Information Protessing Unit,
tf iur davet dsa#iirvr rdrttt$,are"4" 1617 Mail Senice Center,Raido,NO2U"4617
11,80rdmie diameter.8.25^ (in,) 24b.Eter.tnicgtion.3M ONLY. fin addition to sending the form,to the address in
24aabove,also submit a copy of this fotrvI witbin 30 days of completion of well
IL R'edl construction-method:AUGERS Construction to the follming:
(it.taigas.maq.cable.dhm pmth ex:)
Dh4.slon of Water R,esonmvs„Underground Injection Control Program,
FOR WATER SUPPLY MLI S ONLY 1636 Aloft Sexvloe Clnter,Rale o,NC 276994636
132.Meld(gpm) method often 23t.For Water SngMX(1'c injesaTon Wells.
Also subttut on.,copy of this form uithtn'30 days of mlipleufon of
13b.Disinfection hoc, Ammut: well construction to the cotmlh*61th depsomm,t of the cotmty trheat
cotraroctod,
Farm G1V•t Nayth Catalina Dq=uaettt of F. ronmM mad Natund Resotr ms-Dicislon of Rtatet RCsotnrG Re%-lwd AtVd i0t3