GW1-2022-05126_Well Construction - GW1_20220531

WELL CONSTRUCTION-RECORD Farlagcrnnlifscpri[1,
This fond=be uwd.(ar.sfn 1¢ar nw/tipk n•sds
1.��'ett:CUutr:[ctorTttfortatation:
14.I ATERZONES-
Robert Miller FROM T41 0015CRIPT107f
t�'cll.Cnr;tntctrrrfilasrl� R. ft.
2675
NC.Well CbMmctorCcnifuntioinNhnber 15.OUTER CASING tinr•'mu111=cascd-we11si OR LiNTR(ifn
FROM I To I DTA1ttETER, 1 TniC'EtiNESs >vrt�RlA1
SAEDACCO Inc 0 (t.. 431 (t. in ' In, Sch40 Pvc
Ccutthqugy N;atuo- 16.INIUER CASING OR, 18ING.1' aotherinA elased-lwo
FROM TO D11MMUR TIiiCR'NESS' 111ATERML
2,'Vk'll Constfjiction Permit ft. ft:. im
Lisftrltn itiarblexrl7permitslx.Counh;540r,Yirinrice,7iy-dplerc:J ---e
ft. fL.
3.W111.Idsc(checl:�i°c1i dsc): I7:sCRt.t.N.,
Water Supply Ulell:, FROM 1110 bLMtF.'rF:R sr.OTSvrw T1tr"-NESS 1 SrATFRIAL
DAgriculturai t5bitlniClp:t1lP"Wic. 43" ff: 531 (1.- 1" in: o'.lo Sdh40._ PVC
00cothemtal(HeatingtCooiitig Supply) 011esidetniaTWater Supply(single) fE tG= M
Mkidustrial/C6nlutcrci;tl 13Residential'Witer'Su IS.-GROUT.
pp15'(Slk7fed) FROM TO RATERFAL E•\TPL.ACEMENT\fEMOD&MIOUNT
Elihi ration 0 ft. 371 ft. Portland trimi
Non-Water SupplyW,ofl:
17fv(tinitorinG- I7Ttecot'ct}•
Injection VYcB: ft. IL
QAgtt'ifcr'Rccharge EJ4jrduMV'salcrRctiicdiation •tv:SANM1GF1'1rI:LPAChfif;m Ii-:114e)'-
• `• - - 'F'RI)�1 7t}' 11fAYF;H 6t1'� E4XfFl.t(:}:1t4:\T\It'tt1Un
C9AgtiifcrStartgcatrdRccocciy' [75ilnin130f[iC1 401 IL 53, ft. I Silica Sand 20/so
❑Agiiifei Test t7Stvmm ltcr f]m ql'c;
dvv Tprirucntal Tl-hncalogy QSttbsidctacc C6Mrol
2H;DRILl.1NCLOG fntlach allalil anal shins if necessan'1
0Gt tltzutnal.(Clu ed Loop) O7raccr FROat .TO DFsa UPTloxrmbr.aantiim4o4;heck ,.- 4J r4m,tk.)
❑Gc*othertu tl(Hcatittt r'Coollue Returo) ®Odter(explain under A2I Retnatks) (L ft.
ft. ft.
4.'Date%li(s)GoptplclC 4/14/22 N6111DOW-50 ti
ft. (t.
5a Rttll,Grcatinn: ft, (4
MAY 3
ft. ft.
Eiicility,OtiocrNantc Facility iDR eieapptia,'iblc)
ft.,
1248 Bill Hall Rd, White Oak, NC, 28399 ft, U,
Phssiei l'a'lii&ce' Ciiy..iihiibP 21.R!M1IAHIi i
Cumberland Three feet bentonite Seal from 371to 401
Ccnttll P4rcel ttknlirfcatiDn No,(MV)
ib. in ticgtteslniintttcs?jccondstir ttccitil tl degrees: 22.Ccrtificatit)u•
(h.tell ttetdr twrL Gti7gr is;�ntt;eknq .
2/17/2022
Date
6.IS(are)-the well(s): -XiPerntauent or oTeinporarv. F ibn ,ih8'f arm,1'hrre b crrh}d:l[lie n•rllts) s.ar.(l'a e)cmlvrrl
IdIA 15A rYCAC01C01Vjor Lr„m•Ca3/rLmrr
15A NCAC71C Xm.Q Rrld Cflirarrricrfoir Srara+iarda mid rlenr n
7.Ia:thivanp:titfuaauccitin�viciV. CIS'aw or '®No 'coyofffxv-r,ro-rrdlo-ken prpiirkdrrr3tir.urtlmviier,
#Ih r h-a"pak jilt air xlvvim well cwww wfic n lirf9rrruu:cur m. d rtplabi rdir•mr:rnre of tlle
a larrr txenl iB� I n-rn�rtsai�utean ar'R else tir:r, n'tJds•,farut. 23.Site dint ruut'or additional well Retails:
You may use-tlie,back of this pdge.to ptot'9de.ad idonal well site details,or 'well
$.Nnutber of hells ciiustrttcted: 1 Co»sttuetiai6details: You utiac a1D.auacll aidrliliailail pages if necessary.
Firrrinihf da-hrj�irtr�i-zwvv�j-w f rsradn�pw hONLYndrhrlia.sniaavonstruedan,ymixpa
.Mp•viirmvefi:ri:a. SUMNIiTTALiNST 1 .TIONC '
9:Tofatiscildepth bet*land surface 531 (ff 24% For All Welly: -Suhtitit this Point vti(hin 36,days of completion of ir•ell
For lmi?tlreitt#ds'disrttltdrvds'tftdi creait�c+rru Pc @2iVLw„i:2@109) constmctici t4(liefollowing:
10.Static water level belowtop'of eayin Ui,ician of Water Rcvuuroc§;InCornlaEion PtYices4ing Uttit,
df itulee level&vhot!q rtiaatag axle 11+" 1617'Mail Service Cenier,ibileiphy NC 2 76 99-1 6 17
11.Borehole didmctci:6° (in.) 24b.Fnr iufecflgr RON ONLY: In addition to sending the fomi to the address.in
246 aiio''e,also submit a copy of this Lunn witl in,Sul days of conipletion of wdl
U 3itclf eollstructioly method: Sonic constmction td the folloM112.
(f e.sugse,ruaiat}.'snhl direa p'-IX ctc.)
ph•isiott of Water Resources,Underground Injeciion CoutM..Proo-rani,
FOR�YATERSUPPLYIWELLS 0NZ LYs 1636 Mail Service Ceulei,Raleigli,YC.17699.1636
11.i test•' 1-4c.For Wutcr Supply&inlecttnn NVctls:
Also stibii)it one COPY of this,foflit;within, 30 days of catili)letio 1 of
13h.Disinfection•type _. Amount: m-cif construction to the county health department of the couniv.whicro
constmctcd,
Farm0%14 Revised ALWnt'-V13