GW1-2021-04617_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD \' ) For Imcnwl Use ONLY:
This,form can be osed ror sink or rmdtipk rigs
1.Well Contraetorinformatton: e 1
RECE141 All"ZONES
Robert Miller FROM TO I 5KNt;iia7
NN1411 conkaclor Kartre fr.. ft.
2675 �:, nr^t��sirg� 11
NCWdICcvwaorCcnifr mionNnmbcr �f�I:.i4�:3t;01 S.OUTERCFL'SiT1C3•tfhr" tfti�crtsdtwelialORtaltl:R . 'o Ncab
+ OtlOn FROM TO D1A MI 1trrM TRINIV" MAMIAL
pi"u1a�,6 SASDACCO Inc 0 ft, 48' 11» 2- Ia. SCH 40 PVC
Conprm> Nang I&INNU CAST OR1W1NG tm$ttkud-too
rROM TO OtAl4IETBR. I T1tI IMT..SS I MATERIAL
2.11 dl Construction Permit W: R• R» ird
1!u old applirUNP wrU prTM41 t r r.Cmmep,suer,variapwr.Irteakn eir.!
A. fL m.
3.Wcll,lisc(chedc.well nsc): 19:SEMI
Water Supply Wdit PROM TO tHANtF,Y1:R rsti TnC9Cfi1:S5 MAtPRfAt,
QAgricalturat t3Mtmicipalftbli£ 48, fL so, ft. 2- hL 0.10 SCH40 PVC
QGcothermal(HeatingCooling Suppiv) LOResidential Water Supply(si.rogle) A. fL
QlndustriallC-onimercial DResidential Water Supply(shard) 18 GROt£F
FROM TO MATERLAL HIITPtACEMERT ME RIOD Z AMOtTiC7
01ni .tion 0 0. 43, fL Portland/Be Yafaate
No"-water Supply Wen:
n, rI.
OMoTtitorin ❑Re�cm
Injection Well: h•
QAquifcritccharge 00roundnaterRemediation I .�^ .1) Im
❑AgnirerStotg ct+ndRccm+c QSainwBarrict [710.
INA rr.N•t r.T1r n
$ � 50' ft. Silica' Sand 20/30
AAgater Test QStormmtter RreinagcCE. dmcntal Ticchn6 n-
ape [off• gSlrbsiite,Ice Control
20:ORlidltCY t3 athcti�rt1dt17enrtistAeHsli!nree�rti
13Creothermal(Closed Loop) QTmoer FROM I TO DF.sCftImON roabr.60r6 fawwk tv pet 00"et&too-)
i7Geotflermal(Hea" )CoolinaReturn) 00tha(nflain under p21Remadm) 0 ft.. 48' (L Tan Silty sand
48' fL 50' ft. Corse 'Gray Sand
4.Date Well(s)Completed: 3-24-2021 WegimdAS-25
fL tt.
Sa.Well[aI£atii►n: fL fL
tl. ft.
Foc0ilp'OwwrNate I'milit)•IDN(if applicable) ft. fL
117 west Elizabeth Street , Clinton, N.C., 28328 fL fL
PltM=l Address City.and Zip 721:.7tlutki
t b fe
et ee
Sampson F entoaite seal from 431to 47'
Cat oy Pamd lAcaaiiCallou NO,(PIN)
5h.Latitude and Longitude in degtccshnimstalseconds or decimal dagre : 22.Certification:
(itaelt tiew,otw 1 tlotT is s+dik an)
T W 3/28/2021
raigttntnu-o�f'�`:�s,��'r 'c r+ +��^ ti'�►- pxc
6.1s(ire)file wdi(3): xtPCttnanent or DTemporary 4 sr!gnin.K this form.I twerby errro-that the url!(s)was(were)r ornisuered is arrsrdmur
with 1:SA NCAC(12C.n100 ar rSA AFCAC 02C.9201r Well Cojiumfildn SwrAvWs and Owi a
7.U this a repair to an existing well: Dyes or ENo s0(rr of rhlr rrrard has brert provlrkd ra;rhr aril!mrnre.
If this 11 a repair.fill out knoww well eotr 1wilim iR formwrkaa mad erm(dk+rhr narrre of the
repair amdrr f-I'l remarks srz*m or an the bark of this farm 23.Site diagram or additional well details:
You ma►•use the back of this page to ptoxide additional well site deWls or well
$.Number of wells constructed• 1 construction details: You may alsd attach additional pages if necessary
For ntskifdelniecrkaaornrsn-worersV&wells ONLY nfthrheromttanstrmKan,:�aanow �C11a11ti"1TAjr UC170NS
xW wuttme farm. -
9.Total welt depth below land surface: 50, (tt,) 24a. ftr All Wells: Submit tips form %Athin 30 days of completion of well
FarmtalrlplenvllslistaflAlAsf1dlffermi(e.ranap(e-3@2100'aral2R11W) con5tnactionto the fbiloninb;
10.Static water leaet below top of rasing; ((1,) Dhifsion of Water Rei.ouree4,Information Ptoeft4dag Unit,
1f nratrr kVei uobrnr r»alag,We"+^ 1617 Mail Service Center.Raleigh,NC 27699-1617
It.Mweitoic diameter.8° (in.) 24b.Far,tnic gap Wells ONLY. In addition to sending the form to the address in
24a above. also submit a copy of this form within 30 dir's of completion of melt
1.2.Weal constmcdon method: 4 1/4 BSA Construction to(Ike following:
(i.e.auger motor•,chit diced posh,etc.)
Dunstan of WaterResoutres,Underground Injeeliotl Control Program,
FOR WATER SUPPI:Y'it7lLLti,S ONLY: 1636 Mail Service Center,Raleigh.hlC 27699•1636
t3s.lucid(Wm) Method of teat: Uc.For Water"Soggly bt 1pjmIf m'Wclls:
Also submit one copy of this fdrm within 30 dams of coTTptetion of
13b.Dlainfcctinn Niue± Amount _ micil construction to the county fxdNh dcpadmcnt.of the cotml<where
_ _ - wttuctod.
Form GtV-t Nonh CamHn2 MWe rnt of Emimranenl and N=ral Resaw s—Divk1on of\faker RewLrm Revised August 2013