GW1-2021-04179_Well Construction - GW1_20210827

S
WELL CONSTRUCTION RECORD For lrternal Use ONi.Y:
1► 'fhb fame can be asod ror siogk or MAdyk wds
1.Well Contramr Information:
JA.'WATER WNW
Rich Lemire FR ht D CRIPIlO:'
Weil Ckr#MOM Nave
2593A R' M
NCWdlCon=wrCanifwmiDnNnnAa i.btTlP.R. t or niilf3o dVtI1 blei;
FpOM. To DTADtETFrt TI"CKNTSS I MATEPTAL
3AEDACCO Inc 0 (L4 IL 2" in. SCE-40 PVC
Compntty Name -611 NG OR G,f tferaial tlmedaoo
FROM, To DIASf£TRR 71]X""TSS I MAMIAL
2.Well Constrmtion Permit N: ft. ft.
vs<ariapp MN.0 it perms tit.crm" stw-Varmw. rrftoanair)
3.Well Use(thock well use): IMSCIt
'Water Supply well: FRO." Ta PlAPt "It PATSIFY,
i cx%sc .rarl:atn12
Mgliculluml OMtmicipaiMublic 4 ft. 14 M 20 1% .010 SCH-40 PVC
eothennal Menliretool ng Supply) Mesidetttial Water Stlpply(single) ft. it
Clt.f - In
01ndvstrial[Co-mumcial L3ResidentialWater,Supply(shared) -
FR M TO MATERIAL FAM ACE Y\T MEMOD&AMOUNT
❑trri tioD n. tL
Non-Water Supply Well: R
®Manitori Qccor
tnje on Well: .
QAquifeiRccharge MmundrtatcrRcm«liabom
VROAI MATRR1Af, At3111x;s7rm,TH n
RAquitcr Stomsc and Recovery OSalinity Haniet 3 ft. 14 (t: SAND #2
C3AtlniferTcst t,7Stormn-mcr bminagc
fi. fl,
Or_ rtmcntnl Technotolpr ❑SDbsideacc Contra!
9o:-1S'Rll'ANGLOG fdircM tte1Hloar#•abcMsiiffeccess�in
oGeothemiai(Closed Loop) Mom FROM TO D rna:c tnAr,t,ereh *WMcR @
❑Geothrrtrml(HeatiAgCooligg Retum) ❑Other under#2 t Rematt s 0 ft. 14 (L RED CLAY SILT
ft, R.
4.Date Well(%)CompleteM 6-29-2021 Wdlo#TMW-5
R. (L
Sa.%Veil tAicution: (L ft.
YADKINVILLE REFUSE DISPOSAL SITE h, fL
Fad1 t1•)Ybnvucr Nnmr Facility iDli(if Vpt ablt) M ft.
707 Tennessee St., YADKINVILLE, NC, 27055 h. M
Plnsiwl Address City.and Zip 33 t
YADKIN BENTONITE FROM 01TO 31. '
Canty Pared tdetatfeentioo No,ON)
ft,Lxtitade and 14ngltude in degrm4mimrteslscconds or decimal degrecF. 21 Ce WHmtion:
of x_eltfieid,oarc LW
oft is$'At4tfa)
N W 7/4/2021
Signatnfr ofCetti Atli Contractor Doe
6,is(ere)We rell(s): CPermanettt or -MTemporary sy s(grdag tlrif fiom t hr
tub)•rr rnJv thdt the 1#r1NR1 wvr(am)rrmrtnrtred in arcondmier
with 1.5A VCAC 02C.01i0 or 154 NCAC 03C4I09 McUCOM"Cthm Standards and thtrta
7.Is this a repair to an existing well: oyes or MNt► taps�thlx mnnihrrsbrns ptm lrJnd rnthr.ivlt mr,crr.
1f thts it a mrptdr..fit oat bwuq itwV eo (rtfmt iorrsnricn and e.Wlahi the mrart tf der
repair amdrr*21 rmarft arcainrr or rm die bark of thislomL 23.Site diagram or additional tsell detatls:
You may use the back of this page is provide additional well site details or well
8.Number of wells corts[ructed• 1 construction deter. You tear also Hirsch additional pages if necessaty.
For nwtdrde laf rriiwr or mm-,mrer imply mortis ONLY%1rA the tame eonshve ion.3s"can B111 A �T$t'C7C PIONC
submit omforra
9.Total well depth below land surface: 14 (ft.) 24a. Par All Wells: Submit this:fonn itithin 30 days of completion of well
Far medfipit wv9s Qr afi drpthf 1jd6fl'erew fexa ptt;t@;ZM*Ara,201W) construction t0 the following:
10.Static Water InTt below top of casing: 7 (M) Division of Water Resotrrtee,hib matipnPtote4sing Unit.
tf water hurl 4 abovt crisfnR+use"+» 16V!hail Service Center,Raleigh,NC 27699 i617
11.Borehole diameters S.25^ OIL) 241L FDr it Wgp 3M1c ONLY: In addition to sending the form to the address in
24a above. also ohmit a copy of this form within 30 days of completion of well
12.Well C%nstrnction method:AUGERS eonstmetion to the followiliv
(i.e.as r rasa,cdbtc dirrsxpi,sh cre) Division of Water Rem rces.Ut dergtnund Tojection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Re�h.NC 27699 1636
13a.Vidd(gpm) Method of test 24c.For Water Sapp!&inloctioli Wells:
Also submit one cuff of this fonh within 10 days of completion of
13b.Disinfection types Amount �ttt1 construction to tlu count) heilth depmtmau of the county whest
wnstmctexl.
Farm GeV-t Moab Camtine Dgwtnrnf of Ewimnmus and Wnual Rewwces-M-kion of Wafer Rft um R A ised Aft 2013