GW1-2022-05185_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD Far luornal Use ONLY.
This form can be used F1674tirkoi muRipb rscns"
]..V4`c11.Ca�ntrnctor Iitforntatiou:
U:A}`ATLR ZONES-
Robert Miller FROM; TO pF-VRIPIN)IN
}1`ejE�nrararxnrNarne R, R. '
2675 ft. fG
lIClhJell ContmciarCo[tiCt itibnNu>rlrcr 15.-OUTER GASMG(for III ulti-carat"mulls)OR L}NER Mg�`tica6kl
FROM Tel. DIAMEMR• - TIIICEwNESS M,17ERTAL,
SAEDACCO Inc 0 fG- 501 fG 1 611 iq. Sch40 Pvc
collie n}•Naive 16.INNER CASING OR 7 UBING 'eutherrnut etuced400 '
FROM TO DMM FTrsR.. I THICKNESS MATERML
2.Welt Construction l'er mit*: ft. h.. 'nL.
List'affaMlirable teeft pe'iuifs'(ce.Cmrnh.Surd "lrnrinacr,fr)rerdarb rin')
ft. fG
3.Well"Use(t:hcel.:.*11 use): 17.S['Rlf:N
Water Sulgily9Pellt. FnOM 1 TO DlAnre: IZ srbTst73: THICKNFJ5 I MATRRtaL
nA,gtictlltllral 0Nftmiclp 1T%bW, 50' ft: 701 ft._ 611 ill. 0 .62 Sch40 Stainless
Meothelmal(Heating/Cooling Suliply) DiResidential«`titer Supply(single) fG fG Id• '
C2htdustrial/Conmicrciai ❑Residential Water Sltpph'(dratted) �GROUT TO. !rL1TERrlC 1,E1IPG-.CE1tEVT\iFfIIOD S'A\TOLINT
❑hi"ntian 0 ft.` 44' ft. Portland trimi
Non-wafer Supfdy Avon:
Mmunnormg MRccovcry
Iaj pet ion Well:; ft. rG
❑Aquifer Rccfiarge Mdinwidtsnlcr Rc ttcdiation 19.SAN0K.Pm EL PACK Gr a r ifleaMt!y "
FROM' "TYT MAMMAL
h�TP1.AC.I;tilr:N7 Mt:T11I11!
GI�4t(tlrfcrStorrgcaI'd l;€Cotieiy' []SOlinity Maid 471 R:, 75' ft. Silica Sand 2o/40
C]Jrt]Itifci T€st C]Stormi3atc[D }runic ft." ft.
❑gNTcjimcnialTechnology Q�ubsidcn€c.C'.a14Tt,t
20.DRILLINL G'LOG(attach additional sheets tf acee�carv)
❑G:cllrenital.(GlusectLoop) OTracer FROM To DESCKIPTIONrmbr.hardtitmog,41nwkf
❑Geothermal(Heatinu'Coollitg Return) ❑Other(explain under 921 Remailcs) ty rG
R, ft.
4.0,att,*6itOgttiplr'red: 4 /2/22 ZYe11JD#EW-6
ft.:
° r
is Litt Ltrcatinu. fL fG
ft. ft. —
F'acli1Fxx,n:rNamc. facility_jM1 t±fappncable) R, ft. frr�i f,,2DD , TAB , Url€t
1248 Bill Hall Rd, White Oak, NC, 28399 ft,, ft.
Q.
Plq"s`Ical.liid[css Ci[}'..:utrlZip' =ILREMARKS
Cumberland Three feet bentonite Seal from 441to 47,
Comity Pamcl Jags ri,:atipn No,,(PIN)
51),Inatitndc anil i l rtgitude in dggires?rmnut6,seconds tirttlxirnal dcgtc€sc 22s Ccrtitic ltiog:
(ii;t�cll I`>irtdr rnm I,t47pr%�la'�uffli'K.td)
2/17/2022
Sigmtnreaf� s.w� 'rs � -- Date
6.Is(arl'a_the i ell(o)* ZPermanent or. _❑Temporary 11yaignbrg i&t form,-1 frereby cerrify r1 eerie nellfx)vvur f here)car_vrructed is occorG wee
wifh 15A NC1C 0247•,01M or I SA NCtC 0ZC,0200'AKU Cojfifl7iGd},r SIarsdards and A44r a
?.I�`tlriy>l it hair to au,eeiStin �i'cll: 173'a or MNI► c!yis�}rhxs reroirl lirss b 9nt nrmvrla�rrit r.iieil mow,
(#r@tPs 1s,7 rrrr rile lP car rca71 and exyi,tahr the wrare of fhe
r lmrr rit rtrr621 rena",:s liar:or exv the bras-ref d i&fbrML 23.Site diagram or additional well detaits:
You niay use tfs�,bbek'af this pa e,to'lprox�ide additiatial ivell site details 4r l•ell
$.ltumberof i%U,Is eottstructed: 1 coustnretiott details: You:itmv also.attacti addition-d pageiif irecessary.
Fur a tiidrdtde itti vThm Ly'new1y'wer slgrpf>rrv7Js IDYL}'wtrh rlia.arrme constrnrtlon,}t rr eno
.wQm-tmve,t'i:rin: SUBMITTAL IhTSTU "TIONS
9.Totat well depth belm 'land Surface. 751 {fG) _244L Par All �Vclis:."Suhlitit titre sari rttithin 36 daps-tsf conlpktiou of.TCell
Ftri'MuldpleIVeltrllcriitiec,tu�r'(feeoe re)it :99''iIxt2 tM1 '€vn.5Gtictiontoth,cfoltnwing:
10.Static water level helow top of casing, 010 Divisioa of Water R&%'o e%,Information Processing Unit,
IJrealter lee al sboue atitn,atrc"+" IdIF A'1ai1.5eirviCe 0idtcr,,Ralcigh,LC 27694-1617
11;l3orehole'diaincter:10' {ia) 246.For fnjle on Wells ONLY: In addition to sending the form to the address in
24p itW,e,also submit a copy of this form Within 30 days of completion,of irell
I2,'Milmustructiou,method. Sonic c'onstmelidntotkfollowhig:.
(i e:Rttpc nAar}�.can fe diie;c-I.gush cic.)
Division of Water Resources,Undclgl'olmd Injection Control Prttgraut,
FOR WATER Sb`PPLY1%TLLS'ONLY:' 1636 Mail Service Center,Raleigh.NC 276994636
13 t 1T€1d(glrm) 13ctiiod of test 24c.For Water Supply&Injection Wells:
Also stibinit otte.copy of tili� faun within 30 days of completion of
134 bisinfectipn,tvptt Amount• vvcil,constnlbtipo to the county health department of the county-w1wrc
€anstnictcd.
Pomi Gt[�-1 Na>ih Catalina Depanment of EnviroruccutaN\]ararml Resources-Derision of WalcrResorrcrs Revised ALVA 1oI