GW1-2022-03575_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD
a at tr¢emnl I rsc ONLY:
'- 7116&'rm can be asod far slll�l:M nnittiplc n^CO9 � \�
1.WcilC�ntractorllt[oreiatlon: �l
Robert Miller FROM TO I DrSCRIP"ON
Wd)Coniratlor Nate
2675
NC Well CorrrsiYorCertittration Number
I&OUTER CASING cbroutivaird W04,01%Lffl '(9, "
FROM TO I)AMFTER TnX.% MATERIAL
SAEDACCO Inc 0 (L 8' M 4" I in. Sch40 Pvc
i
Comp:rny-Naaae
�61N. dl lcimfditlolcd i
FROM TO. DHAytRTER 7HIICAM99 MATEMAL
2.Wdli Consir "jon ftrmit# (L A, lni
tiaat1 url7pernrihs("c Cbunry..Srur.variance,i`i!kdznffr.)
3.WelMse(chid;well rrs¢): s3°S tIEr±Ar
waterSupph'Well- - irROM, TO IwxWrRR Sr,OTSW1* T"FC"H?S5 I MAMMAL
OAgaicultii[al 13municipallfablic 8' R: 68' ri; 41, h 0.10 Sch40 Pvc
®Geottermai(liealioglCooling Snppty ®Residential water Supply(single) R. tt. in
t]ltid'asniallcomnieleial Mesidcntial Water St 1p (7r1ODT -
IDFI}'(slrirted j .FROM THb MATERLALL I EXrff.AWdM MUMOD AMOMW
❑ [ton 3 ' fL 5' (L Portland Gravity
Non Water Su pplly Wei: R+
❑tvlt�rtitorin 6alttacp� .
Itrjecllon Wett• h-
[aPaquidfer RCclrarge 00mundwalct Rcawdi dion t b VELPACK.. h
rw -V MATRItk4L Rv1iMa 4.c�T.ar: _ n
❑Aiturier.SBore:Ind RtaCOF>ry 17591inity'Hamer
6' R 68' tt. Silica Sand 20/30
❑Atirrifer test ❑Stomm ttcr D►uina9
'ft. rf
❑Erperimcutal Tedulotr v. I�SRhsid rct Control.
Z[I�1TRrGiyh`+[8a.C10'(altaeii:slddit9lin�et heel3 it'irec
❑Ge4dlmw1.(Clostd Loop? ❑Tracer FROM TO n�cxlmati aobr.aardnc�arnrr� sec ere
❑Geothermal eats Gaolln Return) 130dwf4e inunder#21Remarks) 0 h. 20' (L Tan silt
20' IL 58' tG PWR
4.Data Well Completed: 2-2-22 tpltdtJb¢RW-24 58' IL 68' (L Bed Rock
Sa:W dl Locatinn: h
MAR zozz
tt (t
Fagt1q,Om—Nam Faeiliq•IDO(if sW1tablc) tt PWA
1223 Fairgrove Church Road Hickory, NC, 28602 (i n,
PlttstcelAifdriss Ciq,nndZip Z'L.Pr" 1('3
Catawba One foot bentonite Seal from 51to 6'
Cnnm, 1i19n1i(t=110a No.(14N)
Sh.I.W--tpdc and L. ngitullc in dcgmsr4minird6kc6nds or deciraiall dco= 2L Ccetiadion:
(It a ell Held,0e01;100m s sa(li kMo
N W 2/7/2022
Sigr»Irlreaf..,c,a.r.�r c' _ ice- Dstic
6.is(tart;)the wtli(s); NPermaneut or oTempOraty M,signing skit form;1 trerebt•rernfy Thar the wd4si way(Near.)ewnrtnrtted Lrrktimtdmitc
with 154 NCAC 02C.010'2 or'1 SA AICAC Me.0200 Well Cnxafrm rfan a
7.Cc bete a repair tp an bdifing well: ❑Yes or NrN(r Ce�JR ff r114f►ryVrFl�1�WS G!M�MI'irinl r i+tir�irll rinnrr;
lJrhfs fs tr rr{alr,fiA twe bwtm will cowrrrmldr+firfo.tiwrrtloat aw4 expldM rite rtatrUe of the
repair greeter 0-1 nanana, xft-rron&rat the hal-k of fmi f6mr. 23.Site diagram or additional wetl deMils:
You may ust the baeh of this pap co prox'ide additional uv l site details or t«li
8.Number of Neils comxlrtreted: l Construction details. You inav also attach additional paw if nizemasy_
For mailrlple fr crinat Of to h4iMr sVpft ruells ONLY WiltA i/re WMe c41-risirrr04larr,,A"am
sn¢wrftawef mr. CUBM.ITi'AIL.INSTCTC1 ONC
9.Tidal Well depth below land surfa& 68' (ilr.) 24a. For Alt Well Submit tWS fore wilWn 30 days of completion of i*11
For mddpfe wells)fatal)dntuks construction to Ilk fbaotaing;
10.Static water lmvd below top of casing: _ A) bivision of Water Re4nprces,Information Pmeessing Unit,
1f nnrer level b above vdekg:ere +„ 16171M1ar1 Service tenor,Raleio,INC 27699-1617
11.Borehole diameter.10 On.) 24b.jgtl1,, gn Welk ONLY: Utz addition to sending die foml to the address in
24a abode, also'subfWt a copy of[Iris form wilbin 30 days of completion of twill
12.Well rnnstt'sredon method: 6 5 /8 HSA / 6" Air hammer construction to the following:
(U.gage.tararY.UNC,dirai paste CWJ
Division cif Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WKLLS'0NL1r: E636]Bail Service Cealtr.Raleigh.NC 216"-1636
13a:Yidd(rpm) Method of test 24c•For Water SyeplF der Injection Wells:
Also submit one copy of ties form tyitliia 30 day'sof completion of
q3h,Disinfection type- Amount:. well conglnicRon to 41C ccunly health dcpnmmart of the om",-.vhero
coRstrucled.
Fenn G%%r-t Norgh Camlirtn D Wflmem of EmiimimLni and Nana[Rewwocs-Divb1on ofWalerQte3outgs RcvLwd August2f1t3