GW1-2022-05138_Well Construction - GW1_20220531

WELL CQNmucrm RECORD
IMEi form can be use flrh:,4Pgleai mulfilik iwils, For lacrInal Use ONLY:
I..WdlOntrictorliforination:
'14.AV.,%TER ZONES-
Robert Miller FROM 10 1 M:bCR1§q10.i
WC 10coldrWoMan 10,
2675
W-Vell Comm6tor Ccrtjfr�ation Nurn6ey 15.OUTER CkSING OR LINER(if aP1JK,,bk-1
FRONT To, xTER I THICKNESS 3 t:_M LAU
SAEDACCO Inc 0 fL, 391 (L 6" Id, 1 Sch40 PVC
Coft46MY 16,INNER CASING ORITHING'(ga ilhcri at clu.wd4.xm)'
I THWKNESS MATEML
2.Will Coustru4iim rellinit 4"'.
W�3.Wpl,U chtc I u9c): M SCREEN
Water Supply'"Iell: FROM 1.TO I Dr.-%',VtETrl;t SLOTSIZE I T111MNFS5 VNIATRUIAL
39- 'ft; 491 (1.- '6. • '0 .02 ISch40 SEainlesa
Emeotbential(Heiting/Cooling Supply), ]]Residential Witer Supply(A ft. ft., W.ngle)"
C31hdusfiiiYConimcrCjbl Mesidential Water Supply(shared) 18-GROUT
MOM . TO MATERUL 1 ArPLACTN1LNT.NMT110D&miouNr
❑lrii ration 0 ft.: 331 (L Portland trims
Non-Wakr Stipp#Wall: ft, rL
QJecifou Well:" ft. 9L
. ,
Qftfifcr Rccba-r& MdiouTidiv"Itcr Reincdia'do'n 19.SAND.GPtVEL PACK(it anjilleaMe)
36- It.
CIA 'Wi�ot . str, 54• 11. ISilica Sand 120/40
"qu, 36
. I .'11
Myxparimcntll Technology
2,0.:DRILLING LOG(attach adilifional ilk-cli,il"Itecess;nry)
11Gz4ennal,(j21qsed Loop) Eitracer -1110NI To T_PF-5cRi MON'ftobr.klrdliem 1441nich 0)pc'0Fijt Am tk.)
EIG&otlicnnal'(TleatiikW:Cooliiig.Retun)), 130ther(explain under 921 Remadis)
3/4/22
V IZ
ft. 1`11 MA 3=1
rL ft.
FaclLh,MY(tappjic4416
'ft,
1248 Bill Hall Rd, White Oak, NC, 28399
�'� t}: 21%RK51ARKS
01D�Jcid A�W�c cj' itm 2jp
Cumberland Three feet bentonite Seal from 331to 361
cd%uw 1 1rcCT Ira;njirv�,jfion No,(PIN)
22.Certifi
_N 2/17/2022
iw1w—lei�1�1
6.Is(ati-)themell(s): -xPermancut or EITTemporary.
ivith 15A jVCW 01C P00 or.IJA AICAC 0C.0209 Meff Co;ritrticilo;r Sramlarjs acid 0xi a
7.NthL%a reimirto,an t�xi.jtingwcll: 011cs .!')r MNo, -rtpy qfrfih"i�rAfiiai K-evi prov�&,d ri.illy.ify,11 mpner,
If rats da a mAdnfill, krz 4mr '�'f'tw ive'll ras�aarcvitz(a
j=1 r.vpfabt Air elan are 0frile
or cm th�&&4-qfdthrfbrz,. 23.Site diagrank or additional will details:
You c4y use th'-b5&of this N&Jo'pfovide additional well siie..&�j ofiiill
''ifin 'S.Nuttiber6fW019 constructed: constmetion details. Ybu.uiav also7iltach additional pages . essary'.
'yVr�nnld*
XMIM0 amrforvc- - S LIMUTTA L IMLICITONS
9.'71ofid well depth below-Lind mffnce: 54 Fur
It Snibini't this farm%xi(hin.36 days jof'conipfeli6dof bell
�:Iaa EILA
For mwpja 141W"-isi vit'AmIn 3@20(a"dMI 2@IA7) coustilicii6ii to lite fottoui0g;:
10.Static%vater level below top of casinW. A) w4sion(if Water Rom u rces,Infitrmatio n P't-6cco ing,Unit,
1611'Afalt'Servicc Ifitwer level h-oil ove eask1g;am +
It.Borehole 4161nctef-.10 Fx T(in.) 24b. _PfixtJndMllqONLY: Inaddirion to sending(he f6mi to ilia address in
.245koi'e.also$ubtnit a copy of this foliti within 30 tim's of'Coinpletion,of ivell.
I;Z.WFl!coqstrttctlquMethod' Sonic 'cons(tuction to tile fb[16Nt'itlg-
cip.)
Division of Water Resources,Underground It don Control Vro
FOR NVATER SbPPLY NVELL9 ONLY: 1636 Mail Service Center.Raleigh,XC 27699.1636
24c.For Witcr'S6pplt•i Injection WCIN-
Also suliffift qP-1.copy'of this f6rint within 30 daysofcotoplefion of
13h.Disinficetion type: Amount: xi-ell canstnictian to the county f=Jt6 departmcnt or the counly.whcrc
ccinsinictcd.
Fo M,Gw-t N0111i Carolina M-pamnem ofEnvirojuvent and Natiazil Resources-D*-ii1oll oMlalcr Resources lkeyised,Aogust 20 1.3