GW1-2021-05427_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD ForlrtonnlUsc0WLY:
This fontr can tie osed.for sisgie or oniltiplo n'c11s
1.Well Contmetor.Iniormation:
�� 4x VU.A�PIt ti:0
John Bisenman IR M. DRSC9ttVi1(TY
NvolcortmgtoTlKlhtt S ft. h.
4439A �C 1 cP1(<g Utllt h. 2
NCW,41ConumorCw1rmInNu&er C�3$i�(1pCc e �r fiiN iart4: ORtdNfYR: " t 6
0 oM ft, 51 tt. 6TAD , jig, sCs 4o Pv,Et+T ,
SABDACCO Inc
Cont(nmq flame 6.'. NG"Og0)ATN
FROM TO DtA.'11F.TSR I IMC(a!IM MA11:A141.
2.Well Construction Permit k: 0 ft. 58 h. 2 tL SCS 40 PVC
lice all apptitnble wrilp—blif'(Rr-County.Stw,Vcriamr,II(M'v3 etr.)
h. R.
.�.Witt Usc(cheCk Well.Oae):
Water Supply Well: FROG I TO 1tTAAtxyrR St ?x I TtnCUNM I MA"MIAT._
OAS&Ultuml OMunicipal/PubliC 58 ft 68 h. 2 010 SCH 40 PVC
Meother ml(Hendng/Cooling Supply) OResideniial water Supply(siagle)
©indusitialfCorlintercial OReMdetTt l Water Supply(shared) M.1mour ..
rltOat to HATRRML HMvrACf3iMT 14'f OD&AMOUNT
Dfilismticn 51 fa. 3 M AquaGuard Tremmie
Nor- 'ar So Pply Will: 3 M 0 ft,, portland pour
MmoofforingOlttxa�
Injection Well: h•
OAgttifctl2Cc1vivge G7GTaurndtraterltcmcditttion 19 bJl'.RA t
[7Agttifcr Storage and Recovery taSalinitgljarricr Fa " MA t tr1�► f VrMF:7'IOn
75 ft: 63 R. SAND #2
GAquifer Tp1 asl0mm'Rter alta nngc
ft. h.
OF_apcd"=1 d Tcchr ologv OSnb 6=C Control
20:DR11s2AnCr'LOG;a'i`t>ieM�Sidit oiir�tsti�lst�iiec'r� _7 r__ '
OGeodterow(Closed imp) oTram FR" I TO DFSCRrFFtOY o►Yrr ttrrrfecw yH 'vuCk n" rkT
OGeodremmi eau L oO Rentm) GOtber in under#21 Remadts) 0 A. 3 5 (L SANDY CLAY
35 h. 45 It. pwr
4.iMeWc11(s)Cbrnpleted; 9-16-21 IEDNCA-34 45 (1. 75 f6 rock
sa.Well lrcatina:
h. ti
F&s;0iWM%, rNam¢ FacMV 1DN(if applicabie) h, h.
1315 Outlet Center Drive North Carolina 27577 John, M M
P iiad Addtem Ciro'w d Zip
bentonite seal from 56-51ft
C"ah Parto l&nUfk*UoaXo,(PIN)
5h.14titudc and t ongitudc In degrecs/mintitss/scorinds or decimal degrees: 22.Ciertirkation:
(ttuetl tied,me wons is sndllek(rt)
N W 9/19/2021
Sltnrlereof ,•- ••. v.,r-r..,H ^� ~'��:Dart . - -�
6.Is(are)the weli(sl: ZPenmanent or DTemporary i't
By ii 464/hit firo.h, ,, • .if-ti«.rx. 4sl i 4iti h r:c/tmtrtrYrle$k anrOJt�lAt4Y
ufP1r 13A NCAC 43C 'ls-+e-�'r:`';t;k4 wt�:�MO►t'elt Cruuirn�rflan Srendania anti tJa�a
7.hthiisrepairtoanexifingwell: zVes or ❑NU mrsrfthirrarorci�sGrrnpfm•&lyd nnbrxritsrrrnrr
if shin h o wpdr,fill stir klrrirsw wrll cmanwdtm Wornatkn4ad explain Ar norwr of O
rrpair Mder#2l rcworkN s*..A"or on the bad of fAb forM 23.Site diagram or additional well details:
You mm,use ttie back of this page to pntt de additional vivil site details or well
S.Nomberof yells constructed: 1 construction details. You may also attach additional pages if necesseq.
Formuhi e1"Jnionor"M-wwr?,stgrptrwelhONLYnfrh die rnMeWnspwrOMP"can
n0ftuaau foam sunummmicnoNs
9.Total wdl depth below land sutiace: 68 {R.) 24s, For All Wells: .S6bttdt this fonu%ithin 30 dnt%of completion Of ti�11
Fart+eaalrijrde calls litr aA drpdaT(/d trrnr larpnij>lt J4 7AD`nut?�!!'Yt [pnstntdion to the following:
10.Static`water level below top of casinr, (ft,) Division of Water Resourtts,Information Processing unit,
11 nraler lri ri is obuur cv ant,RM"f" 1617 Mail Service C`enta.Raloo,KC 27609-1617
11.Borehole diameter 12/6 (in.) 24b.Fnr iniceNon WeIisONLY: in-addition to sending form to the address in
24a above. also submit a copy of tttis 1brin,within,30 d4s of completion of u ell
12.Wre#icntrSttSe tD:fnetbod:HSA/Air construction to the following:
(Lt.sW.mtaty.whir,diM posh.cxc:)
Mision of Water Remo rces.UtdeMmund Injection Control Program.
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Ctnier,Ralelpb,NC'27699-1636
U&Vi dd(gpm) ,Method of tmu �-For Water Soak&lnjea for Nicks:
Also submit one copy of this fom't Uithin 30 d*,s of completion of
13b.Disinfection tvpet Amount: well construction to the county heath dMM"cM of the counh where
coTntmcted.
i
PonnOV-t NodhCarolinaDegmuncidefF.mkor mdandNahuaiRcsonnxe-DnisionofWatcrR mum Revised Aigid2013