GW1-2022-02953_Well Construction - GW1_20220301

WELL CONSTRUCTION RECORD For I tercriml Usc ONLY:
This form cin be used for single or multiplc sails
I.Weil,Contractor Information:
1L%%`ATERZON19�
Robert Miller FROM TO I OF3CRIPTION
%VC11 Cortmao?Kmew
2675
NC NAlell Continclor Certification Nimber R CASING rorinuftI.6Wwkns) RLIN�ER(lfav kable)-
FRONT TO VIANIXUR TIIICKiNFSS MATTRIAL
SAEDACCO Inc 0 ft. 12 ft. 2-1 SCH-40 PVC
.INNER TUBING iii0ib"aliclowdolopi)
FRONT TO
TO D AIFTIER THICKNESS MATERIAL.
C1 it*. (I
2.1sVellCo'nstivetion? in ft.
• Lill till applir-ahle WHIPF""its(ix. Varianneq flerlicrt eir)
3.Well thst(chock well usc): '15-3-FRES ! 777
Water Supply Well: FROM I TO I DIA'-%tFTr.k I J%A)TSI KN't1,0- I MATF•RiAI.
12 ft. 27 ff. 1 211 '1 .010 ISCH-40 PVC
OAgficultural 0Municipallhiblic
043cotbernill("CifingeCoo ling Supply) 011esidential Witer Supph-(single)
.. ...
01ndustriallComincrcial 01tesidential NVI(cr Supph,(sliamd) 8 GR
OUTL
FROM TO MATERIAL. I VAIP1 ACrM92'T trMOD t AMOUNT
13irriplitin 0 ft. 8 ft. Port land/Be12A=A te
Non-Water Supply Well:
6%lonitoring 011ccovcry
Injection Well:
[3Aqiii1`cr'Rosh orgy Odnaimdwnicr Rctucknion 19.SANDIGRAVELPACI L lt)
FRONT To I IAM.I Ni)7"011
0Aquil'cr Sloragc and Ftcco%riy DSilinity Hirricr 10 ft. 27 ff. Silica! Sand 20/30
bAqiJifcr Test O.Stornim-nicr DriinaW It. (I.
0E\PcdmcntaI Technology oSubsidezricc Control ",20:11tit.11.16ING LOG(attach
oCkoiltennal(Closed Loop) oTratcer FROM To OPSCRIPTION(volor.11111,41161,101111'"Wk lvoe. in"br."t.)
DGmtheitnal(14taiiiqlCooliq Return) 00ther etexplain under A21 Retnar6i) 0 ft. 27 ft. Yellow fine silty sand
4.Date Well(s)Completed-. 1-28-2022 Well IT)#TWP-4 i tF-
52.WC41 1,11CAthin: ri. tt. MAR 0 12029
Food Mart #10 IT.
Fad1iiyA)evncr Nanic Faci1hy IDN 6rapplicab1c) D.Mv.NFM
1150 Virgilina Rd. Roxboro, NC, 27573
Physical Addmss,City.and Zip
Person Two feet bentonite seal,froza Seto 101
Novel Widirswtioti No.(PIN.)
r
Site.Latitude and Longitude in degivc0minuteslAcconds or decimal degrees:
22.Certification:
N W 1/2 9/2022
6.16,(W)the well(s): Pcnnancnt or oTemporary eigainy this fimm I heeh-s.jerttfy thin ihe ve-efle`.v)%vs ivirr)eviiii-tiveied hi rrivor&mee
ivith 15A NCAC 02C.0100 ar/Sit NOW 02C.020.0 urell(7twisirvit-1011 Srolls4efrfft rum 1hal 0
7.Is this a repair to an existing well: OVcs- or ENo
if ibis is a relkile,fill tau famm well coa-vinwilat)frrjanrxtrlon awl r.kplohi the toomfe of the
23.Site diagram or additional well detaN:
You inay use live,back of This page to pfovideadditional well site details or well
8.Number of wells constructed: 1 constiliction:details. You may also I Attach addilioml pages if ftvessary.
For mishiple hVe.rion or im4l.warer sitWy ivells ONI.Vii*h the-some conontertime yotg corm
xwvllir One form. SURM11EAL INSTUC13ONS
9.Total well depth below land surface.- 27 24a. For All Wells! Subtuil This lbrot within 30 days of completion of well
For)"aftiple scells list ereO(leiveles if dlft'erov(e.vmijp(eJrd12tV'an.1 249,MY) construction to the fblloning:
10.Static water level below top of casing: 00 Division of Water Resourem Information Proceming Unit,
if motet level if ahreve ajsNp lost 1617 MR,,SCSV,ee Center,Raleigh,NC 27699-1617
11.Borehole diameter.8.2 5" (in.) 24b.Fur luinjJitil MIL,;ONLV: In addition to sending the farni to the address in
24aahove. also submit a copy of;'Ihis four within 30 days of completion of well
12.Well construction method: 4.2 5 HSA construction to the following.
(i.e.me,_cr rotary.cable:direct push ctc.) L',Oh
Division of Water Resources;Underground injection Control ProgrAnt.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 276994636
13a.'Vidd(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this (bi'm within 10 days ofcompletion or
I3b-Di*inicetianh_p _'— Amount: well consmiction to the county h6lth dcpqtimait of the contity whcTc
e:
constructed.
Po on GAAl_I North Cato fina DWn ribmi of E avirotunc ta and Nat siral Rcsourccs-Iliv is 1011 of%Valer R mut-m- Revised August 2o 1.1