GW1-2021-05457_Well Construction - GW1_20210615

WELL CONSTRIJMON RECORD For trtemw Use oN1.Y:
ns form can be asod for sftk of rtailtigic"US R s.-„`C✓s..
1.Welt Gnntrnetor_ItttortTlatlon: -
t4 TA tt:
Brian Ewing VR M To Dt?SC-Rrm"N4
%WtCo"kaCit►Haft fL n. Jir:S0if;;*t"%en rCseCSin.
4240-B
NCWtffCawwarCanif1cdfonNnnber #807PR. ING a *RdwmfiRLEM ltcah
FROM TO nunferrmR" TflICiCRFSS MATCRIAt.
SAEDACCO Inc 0 n, 19 fb 2.25^ le. NA Steel
Cema:rn}-t�►aic
FROM TO Di OMTr.R TtITCKNTM MAWJUAL
2.Wcfl C•4►nshvction Pcrmltlh. W10400557 ft, rLn.
ht
l�gatl eppiirable well prrm#ts fcr.Gnunte,Suer,Vrrrianrr,Ir}'aeYlal err)
3.Wdl Use(checlt well Oic):
Water Supply Wdl: PROM TO DI XTRY LR SI OT IYr nl]CIKNTW MATKRIAT;_
DA96culttital olvilmicipal/Pablic 19 R, 24 ti 1.251'1M .004 NA Steel
OGeothetntal(ReatinglCooling Supply) OResidential Water Supply(Single) A. tt, is
ClindtlstrialfConimmial ORcsidcn6al Water Supply'(shared) FROM 01)7`
liftOM TQ MATBR[AL Q\iPLAG7'N'6 rAEiilQDfiAMQL"Rl'
ofrri Lion it. tt
Hon-Water Supply Well:
A.
OMonitorin ❑ltecoi tt,
injection ell: n. h.
oAquiferRccharse oGtoundnitterRetoodiation
VRO W P.RIAI::_ R71rpt,ACTittrlir r:7Yt n
MAquiferStoiagc and Rccovcty Mal nity Barrier n, n.
OAquiter Test oStommatcr Drainage
rft.O ExpcAmcrital T=hnotog OSubsidc=c Cort"I
xtr:_oRn.�t�•a a`►t11ic1i�itdtilmY'hrrt34t"" `
❑Geothemml(Closed Loop) oTraeer PROM TQ FIESCRtrrtON a»r WomaaagncTc ren erg
oGeothemnal ffleafirwXooli ng Return) ®Other( . Under 92,1 RemafS) 0 (. 15 th FILL SAND/SILT MOIST TO WET
15 ft, 24 i. SAME
4.01teWetl(s)COnipieted 5-25-21 WeiIM#IP 1-3
ft. ft.
So.Well L ocatlim: ft. tt.
Entercom Facility n. rL
Ftic114J '0wwrNmw Facility IDB(if appiic bbk) tl. ft,
367 NC-68, Stokesdale, NC, 27357 fr. n.
P)p'sicalAd4mmC'ily.and Zip 7I'l-011
Rockingham Injection via DPT "tooling IP 1-3. 150 gallons
fxmn}' Panel Idcat7fRatiottNo.(iNN)
5h.141!Wde and Longitude in dcgr eeslmimtialsmands or decimal degas= 2L Certification:
ttf xett tTetd,uric lartidt�is Stdttrkm)
N W Bra,n�.Ewing; 6/7/2021
Sigrah t ofCcitiftd Wdi co,atacwt Deie
6.U(rat*)the ttel](9): oPetmanew or mTernporan' By,ring thin fofm,I hereby eenN .rh tt Ae"elks!VVI fmrrrl c,da'rnt aed in asreo4wee
%1*)JA KCAC 02C.0100 or I BA NCAC p►:C.02t}Writ Caasrrtw-#an SMnodws and ilea a
7.U this u repair to an existing well: Me* or I&No COPY O'rhir MWrd hna brM PAU'i&W M the UVII fn,nor.
ff W.4 h a rep dr.f 11 cmr.trr""nw11 emautwdi m MfonwrW mwl rrplaIn stye mrwre of the
repair W derf?1 remara x srrrnnn dw(An die bawl:of dps farm 23.Site diagram eradditional weal demilt:
You tray use die back of this page to pratide additional well site details or well
8.Number of welts constructed: 3 oons[mcdon details, You trap also attach additional des if necessary.
Fc r m4 diWe InjKtka or mm-itwer j*pdv as is ONLY a frA rht rm r emtstrwrlian,ww rant
sub"I twee form. SC BMnTA .�`CT1tL"IYONC
9.Total welldepth below land surface: 24 (rL) 34a. Per All Wells: Submit this form within 30 day8 of completion of,well
Favor trrnlewer�alisrrrltdrp r¢fdijfrrrmtermrnste�3 d(1fN'a>uf?Ct.tfuJf CpnSintctiuntothc:following;
10.Static water level below top of casing: {R.) Dilision of Water.Resanreec.Lnfannatinn Processing Unit,
lfHvver kvel is dboie raa ng,ices N+" 1617 Aiaii Semice Center,Raleigh,NC 276094617
t 1.Boruhotc diamctcr 2.25^ (m,) 24b.Far iUMM H'M ONLY:;In addition to sending the form to the address in
24aabove. also submit a:copy of[this fomn within 30 days of completion of null
12.Well construction mCthad:DRIVEN Construction to the following:
4i.e.aritlx.wbiy,'cable died pull►etc.) Dit lslor of WaterReiaon rres`«Underground fnjeclion ControiProgram,
FOR WATF,R SUPPLY WELLS ONLY: 1636 Mail Semite CtDter.Raletgtt,NC 276994636
13a.Y1014(gpm) Method of tC+t: 24a For Witter 5nUWX&1ploctioh Wells:
Also submit cite copy of this forin nsithin 30 days of completion of
t31t.DisinfectionAmount rtc11 construction to the County luc:ntik del moment of the county whew
constructed. {
Fetm QA t Nmh Carolina Dada uwm of£nrimmnmd and Mnva)Rcwtnocs-Dh*jaa ofUlsler Resownes Rc%-imd A>6t 2013