GW1-2022-05153_Well Construction - GW1_20220531

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WELL CONSTRUCTION RECORD FarltllcnmliTscONLY.
This fortis can be ascd.f:fT sfn&az mWlipk WcI15
1:V�ell,CootnlctorLrfa"rnration:
• � �1J.,I1`ATLR.'LONF:S
Robert Miller FROM TO. DFSCRItsrit)Y
tiY¢1E£otxntcfirtiiarnC � fl. ft. i
2675 ft. ft
1+C.Wcl1ContiaciarCeriiildi'lioaNiimfi& I&OUTER CASING(ferrn till Era il'rlctisl0RLRVERtfE.tii licable
FROM. TO PI,►i►flETfi& Tn1G[i..�'ESS lU;\TERIAL
SAEDACCO Inc 0 ft. 33' fG J., iq, 1 Sch40 Pvc
Covina}-Nano 16.INNER CASING OR I'VEING geothermal clu Ld-loa
FRO\1 TO DLMrETER TTtitTaE54 5L\TERL\L
2.Weii Constr ut tion 'cr�ltit R. tr.
l isFtrll rppilienhJr.rrtrl/ra rmiti(fie.Enunhvsloh;-Ynrinrrer,11-1cu[ca ctr:) ft.. rl i+e
3.Ws11.Usa(chcri::►ti gli iisc); 17:SC REF.N
"litmrSupitivYl'cli:. FRt)%l I TO VDUNTF.Trlit 5L0TSI7F I THICKNESS I SIATFRTAL,
❑Agricultural ONfunicipaVN.li is 33' It. 43' ft. In iR' 0.16 Sch40 PVC
13Cwhenral(HeatingfCooling Supply): DResidential Water Supply(si oc) ft' I (L'..
®lndustriaVCanulietcial, t3Rtsidential N�rlter.Supply(shlrrtl) 8.-GROG Tn. tiIATERini I ENIPLAM,DENT Msrnon s AMOUNT,
❑1t'fi 7tion 0 It.: 27' It. Portland trimi
1!'on Water Suppyy,won:
❑Monitoring pRcco►trp
IuJcction Wcll:, rG rG
ClAgllifcr Rccharga 17GroundnnterROtcdiation 19.SAND.'GR s,%FEL PACK(if a t rlieabte)
c,. 'i'ROA1 TO -Ainrelit4r, K�1Pl.+►t'E:\1F:NTVE'rntln
ElAlinfcrStorage aTO Rccocrly CIS trinity$'Irriei
301 R. 43' ft, Silica Sand 20/30
[7 Ae)iri Test. I]StormSv itcc l7ri%i 7©c.
QExperi[ncntal T�11n�llp�)• 17$]tbsidertcc Cutd?Dl
`1tt:DRILLINC`LOG(attach ad0ifiunal shccti if ttcccscarSl
❑Geolhennal(posed Loop) D.Tracer FROIT .TO DESCRIPnOI`twbr.banlriiai;xd3'ntckt Itlsrrc,rig
❑Geothennal(Fleatickt ICaoliue Return) ®Odier(explain udder t#21 Retnarks) ft.. tG
fL, (G
D tC)Vell(s)Cdfiipl jed: 4/14/22 .,Aydl]DP OW-27
fG
So.Y1!ell Location:
ft.
rG rt MAY 3 i�
Fe4ilityaYlretay rNnna Facil'ny TDR tiCapplivabJt> ft. ft.
1248 Hill Hall Rd, White Oak, NC, 28399 ft. fG tJrti•
Phsstid,iiidasi.:City'.andZija
I RI:ntAxss
Cumberland Three feet bentonite Seal from 271to 30'
coin v 11an:e1 Itl:nlifiCA1it3n No.(PIN)
b.J<-;1 6drand.Ltittk6de in¢4),nreshntnu cslsccouds rar ticcimal dcgrecs 22.Ccrtifiiatitlti:.
(Ili+fi1E r etcidtrti 1aU7otrktt�tdl7ti nl)
N 2/17/2022
SiemWroaf�: awn 4':�s �"�--- .Daft
6.1s(area the.\\'ell(a):MPumauent or 17Temporaryr 1ry,3i ndn g ahu brra;.l'lrerrb•cent y lhaf rLr n•rl1 s• war t�trr gnat rcled Lracearrlan-
lvi&15A NCAC 02C.0100 r ISA NGtC-'Ore.('2701911'ell Coiratrricdoar Standards and i/arir a
7.hthirarelklirt6an,existing li'elii ®Yaw .iir '®No. c sb3(Jiis,rrebirdraasb�eri'i;rarirhdurilic"aiellmvhrr.
It INS is,a we"If&*rupntet&rpa brforywilot and cap labs rdae naPire of the
r4mir tvtttl�r&31 rem,ii,&v, nit C'M the h'o�l,ofdiis farm. 23.Sited!
ite dial;t�m'or�additional well details:.
You may use.tli�slack of this page,to pro-.Jde additional cell site,detaiii:or iiiiii
S.Number ofai06mitrueted: 1 Construction details. You.itiayalsa:aitaelradditioitalpagesifir.'cessary.
Far airaii ige 1,q rh�t t.N nnl-uwrer stipp i,-rrelfs.OXLY wirli Me same c4nstrarllon,yPjmNm
.tutrnut txic fi:rrn. -S[iBN11T'1`A 1,IM CITONS
9.'T4a1wW Aepth below-land mtrfac!n 431 (iy� 2./a..Our All,Wells: Subndt this fti"riv yd(Wn llb days of-corrplctiou of well
Forrtraagpla con5tntctio,nto the,folrouiu�;
10.St:a tic_water le►'el.h"elo\\'top of rasiu�: A) Divisidi of Water Rezour'a Information'Nt eessinK Unit,
If)vdlee level h-chore eusok,-,rase"+" IG17141ai1 Sea icc Cen1&,,RAIcinhr YC-1760-1417
It.l3onchole diainct&:6 a 10 24b.For injectttrt WeRv ONLY: fp addition to sending(he fomi to the address in
24a above.also sulrnlit a copy of diis.fonn i itlun 3ti day; of completion,of►reil
12:3Y'cltrronstnlciiou method: Sonic construction 1011te 6nowing.
ioiaiy.snblc;,d n t pasta era:)
Division of Wati,r Resources,Uiidirg pond Fnjccflon Control 1'ragrxnr'
FOR WATER SUPPLY WELLS_ONLY:' i636 Mill Service Center.Raleigh,NC27699-1636
t3;r i dd(gpnl) 1'lethod of tcsh 21c-For Water Supply&inimfi6n Wells:
Also subiiit aua c6py of this folni Iritbin 30 days ofcolupletionof
13h.6lsinfectiun,trp4:, Atnnunt: ►ell.construction to the c6unly health department of the counh;where
' constrtictcil.
Form GSS'-L Noiih Carolina Depattment.of Em•imsu rtn aud;Vanish Resources-liivklon of R'aicr:Rmoues Revised August 2013