GW1-2022-05170_Well Construction - GW1_20220531

WELL CONS' UCTION:RUCOR_ll Far.Tlxti�u�.,orri�:
This form can be used fm.single or multiple steps
1.Well:ContractorLtfarutation:
1.1.11 ATER ZONES
Robert Miller FRONT: To 0"CRIPTION
�Vc1lCormmuctarName ft. ft.
2675
NC Well ContmclorCenificntionNnlrbcf 15.OUTER CAStNG[for"wnd1kascd'racnsl OR LINER of a a able)
FROM. TO. DUIMETER: TfIiC[iNESS hi;\TERTAL•
SAEDACCO Inc 0 ft., 40' ft. 6" tu. Sch40 Pvc
(crtryP trt}-Nana 16.INNER CASING OR 771BING 4Leo1krjnaI c6;ed41x
FRONT TO DIAME-TRIL, TRICA'NESS NIATERML
2.Well Construction l'milt : R. ft. o�
J�rt'ailappilicahJr x c11 p¢imlts ft:r.-Chirnry,,,51 o,Marinrce,I1*6M rrr.)
ft,-
3.WeIlf3sa(checkiVell tisc): 17 SCIt1_LN
Water Snllpli'Well: FROM I TO UfANIF.TF,It SLOT 517F. 711ICKNESS -NLATFRtAt,
❑Aglicultntul ❑Ivfunit ipallf`1fUtie 401 'ft: 60' ft. 6'i in, , 0 .tie sch4o stainless
OGeolli mtal(fieatiTielCoolin^S 1 1 ) 011csidential Writer Su l ft f4' in.
ul P Y PPI}'(sin^e)
131tldustriaUConintefcial ©Residential Water Supph-,(sbired) 1 18.GROUT
FROM TO. MATERIAL: EAFPLACENMNT5tMODd`ANTOTINT
❑Irr ;1hnn 0 ft.' 341 ft. Portland trimi
Nou-«'aterSupplyWeR: tt.. rt..
❑Monitoring, �ItecoNrl}• '
Ittjttfrct Writ:. ft. rt
EIAtlliifer Rccfi3rge Mroundri:itcr Retncdiatien 19.SAN Dlt'.MVEL PACK tir a rl lcaldc)
'FROM TO imrruw NIP]ACFyIVATNIET1101I
13A(n44 toiagcandltccovclp WilinityBdmcr 37' "R. 651 R,. silica sand zo/4o
❑Ails►ifcr7es# I75tommitcrf3rsin0gc
131ryxT rimcntil7b,-hnotogy, CJtiahsidcnccCuidcol
20:'DRILLiNG LOG(allach additional shecls if MescarN l
C1Ckxitltcmtal(Clgsett.lorlp), OTrlct'r FRONT. TO 'in er1
❑Gr odtennal(Maiinu'Cooline Return) ❑Outer(explain under 921 Retuatl s) ft. fL
ft., ft.
4:1}Jt, �Vcit(a)Couilil++l; 4/5/22 Si°e1111a#Ew-17 ``
fb fL
5a W�11 Lltcatinud ft. ft.
MAY .7
ft. ft.
Fdcjliiyr'Oi vmlvrNnme Fac7Hy iD.(ifappllcablcj ft. ft. --4nfOrAYi,,,
nlarn re, Tg Unp
1248 Bill Hall Rd, White Oak, NC, 28399 ft, fG
Physical Address.Cat}•.and Zip 01.REI%LkH1iS
Cumberland Three feet bentonite Seal from 341to 371
(ttuuty 11=0lrloilfficc,•ltiunNo,(PILN)
Sb.I:ntitndc an'd LtinlItudc•in dcgtves/minutcsl3ceands 6r dccimirl dcgl-ceS. 22.Ccrtific ltintn
(Itii011 i�41r ebai 1a47oua is'SttTGCleud)
N �Y 2/17/2022
Dale
6.Is W1?-mianent or L-ITemporary IJ•si•»iu ehir'ermr a/rereby rcrfi a rLrn•.tlir vrll s vvs.
J" f (J {p•ij cpnuiuefed hr-accordance
with 15AMAC-02C,01A7 or 15A NClG OX,0:00 rill C9rrif1wcNa1 Sramlarsls and ilhar a
7.Is this a repair to an esistinr tiVclh OYLs .or MNi1 c�rfrr'njrh/r rrrn;rd f nsln'sn prnrir&�ro ilia IrrN mullet,
,(d rd�lc�a f�,m�r'r,tall caal,firrrtlty at��•71�temtsrnrsrlc+ra ltr/Onlurrdwr itv.rl t.tlilalat r{ic-nwnara ref ttre
relauitRmlti �t rv�aiirCsairarou ar rxe rlie Lruk c tJtis Jorur. 23.Site:dingrancor additional well Retails:
You May t1Se the back;of this Oge.16,provide Mdifional well Site aetail8,4r tt'elI
R.Nutuberof ikells tronstructed: 1 cons(Metioli details. You ntag also:attach additional pagos if necessary.
Foa imitla[,4e ittki4m uN ntxi'=joarer si,p r wi,&OjVLY arirh r1je wme co4triteflon,yNt.ctm
sm(wiat avc,t(�rr7. SOBIIf[TTAtL iNSTtTCTiONS
+9.74i4l isell,depth Uelow-land atrrfncc 651 (ft.) 24a. 1 nt,lltl.Welis:. Suhlitit_ Usis Earn within 3fl days of contph tion oP well
Ft�rrreiProloµe:l7x'liar�7tl, nhs'l/tJ itrlit�rrairrnlr 3 elk)"'oral? Jtkr)' consfinetionto(Li o.110%ing:'
10.Static eater level biloe top of casintj: (ft.) Divisip of Wtiter Resouineii,Informatinn Prnecssing Unit,
if water let-el h rpLaeti tw(ag;last +" 1617'hbit Sci•icc Center,12rlcigh,.NC 27699-1617
11.Barebole diametci;101 (in,) 24b.Far fnlectlnn 3V6lc ONLY: 'In addition to sending(lie fomi to the address in
Maabore;also submit a copy of this.fonu NVitltin 3O days of completion of null
12.Well construction method: Sonic rotisttucti6liiodte1bII&%6tig.
nuger._rainlp.''cahlc.dinripushetc.}
'Division of Water Resources,Niidergronnd tnjection Control 1'Ingralil,
FOR WATERSUPPLY WELLS ONLY I636 Malt Bernice Center,Raleigh,NC"27699-1636
I ja,Yield(grim) A4ctliod of test' 4r—For VVdter Supply dtt Injcct1nn WON:
Also subiilit one copy of this f6nn %%Rhin 30 daps of completion of
131x bisinti&)n,*pet, _. Amount;. well consimction to the county hetilth department of ille cctmty whcro
€onsimctcd,
Font;GA'-1 KDnh Catalina D.-panmcnt.of Erreim=ctu ant;latam]Resources-DiviiIon ofWaicr RLsatr[-- Revised Augtu5t'_V13