GW1-2022-05186_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD Forlrtcrnnlirs01 l :
This rorms6gi bc'uwd Coisfng)car rnultipk nc[!s
1.Well Contractor Information,
t•t.VAUK ZONI:S
Robert Miller FRO1111. TO DFICRtPT1OS
W01CmAradorManic,
ft. ft.
2675
NC.Wdl ContmetarCortiWtion Niurber I OUTER CASING(for mnitl cascil'ac4lsl OR LINER tii a ncahkl.
'FR03T TG DUMETER• T1nCKNESs r r,rATERrAL.
SAEDACCO Ina 0 (t,, 76' fL 6" in. Sch40 Pvc
ftir�q,ur}hGuw 16.1N.IIER CASING OR TUBING'"•eolhcrmat chiced4 oa
FROM I TO DG4itETER THICt."NESS MATERIAL,
2,Well Construction Pct mit n:
1.isftrllergi'lirnblesa2J1{reimiti.(i:c.Crumh!;Sfrr!r,-Vnrirrrrcr,Iryenvortelaj
ft. ft, in.
3.Wc1LUse(ehcclr.ii=ell usc): 17.sCRI I:n, -
Water Supply Well: FROM 1.70 DrAME:TF,R SLOTS,17 i 'IH["—NFS$- I MATKNIA1•
C1 octlitural cimunicipaUPublic 76' ft 96- ft- 6" iR• -0 .02 Sch40 Stainless
b6cothcrnrtl(Heating/Cooling'Supply) DResidential AVIifer Supply(single) r fi.' ft.,
©IndusWaVConmtcrcial ®Residential 1Vatcr Supply(shared) l 181 GROUT .
FROM To MATERIAL EMPLAM,MNT AWM0D S`AMOUNT
El Iniiption 0 ft. 70' ft. Portland trimi
Non-Water Supply.NVelk
l7Moni#oripg 0011 coNv y ft.
Injection Well:, tt rL
0A fit►•ifa:rRcC argc Do round5i"ItcrReawdiation 19.SAND;GPUVELrACKfira pllcabrcl
C.
'FRf►5r' TO t11A'CFEft\1, F�1PI.ACF�116:tf 1'StFTitittt
I7AgmtcrStoiageantii?ccotict3' Q511inin flarticr" 73' ft. loll ft- Silica Sand 20/40
QAgi447`cs# ❑51omtSi�ttci Drun:loc, —ft.
fL
Ql~.ylclirticntal°IL�;htltiCng<' 1-J�9tbsidcrE:e+Cor:(rol
20.DRILLING LOG(ntmach additionat sheets if acccssan•l
❑Geothennal(ClusedLoop) ❑Tracer FRONT .Tar PFSGR4P170Ntcakrr.harArica.u-1;'n�clit to .del
❑Cn*otla mtal`(EIoatit�e`Cnollug Return) ❑Cdtzr(=plain under 92I Retnaihsy f4 (t
#:I?aic��'cit(s)CoUlpidled, 2/7/22 �SreIIIDFtEw-66 a ram`
ft.' tL '� ..
5a;WcII Lrrcati+tn: f[, ft' MAY 3 1 202
fF, r4
Facilit}+k�1vn�rTlanc Facilh IDm(Cappli*gj n, fa. I(1 rSfff " fe-9 n
etas:- �
1248 Bill Hall Rd, White Oak, NC, 28399 ft.
fL
P]lssrirl Lilili s�City..andZip 21',REMARKS
Cumberland Three feet bentonite Seal from 701to 731 Five
cottnl}! Yana lai.rgiCic�tiam•Na�•.tP111) foo
8h.L atit ide and LCitietntic 6',41c seconds or decimal degrees: 22.Certifit ttioa-
(if ia1D,3�Itlr avrilxL7ort�n i:�afl icy t�I)
l� W 2/17/2022
Doe
6.Is(are),the ivell(S)r MPir UMCKt or 177cmitorary �p.s71,nrng t�4ir funs;t frerrbj•rcrrifc char the n•r11{x)K-ax{tven}cunYrrurreJ Gr:a�`eorrlance
ivifh 15rt NC JC 02C•�10t7 or ISA NCAC 02C A20q 1etl ro!rarrricriar Srardards arud-rlarrr a
3.LtfiNarepair6anemstiniovcll: 9lYCw .fir 'NNo CCOi',offlin'Freoir8440,•7ra`nrnridiMiaihe,iklMiler,
(j iks lz_a refirlr,fill'aavr�` t+ well cwasrrrarioa A(forrrrrkn an!M a aglahi the riarare of Or
repair=der4-7 rc w rCssecliza or an flee Zra'k of this farix 23.Site diagram or additional well details:
You may-ase.t3 d'bacl:of.this 0jo,to provide additional isell site"details.or iscB
8.11umber of itelis constructed: 1 cousttuetiotldedails: You utar also attach additioual pages if I='Ssary.
Faar rrr�dri�fe iru4�rlaul.tN RdYf-curer rtr��[v Iri7lx t,7evGY udrh rJiesrrmg tvirrstrrrcGwb}�aur.a�
sr wutasve riv: suBmiTTAL iNsT T.`PIONS
:Tatgl well depth betoiri:tndsitrfae� 101- (1t,) 2•la. Fnr Att-Wills: Suhndt (lus,fumi ttrilhin 30 days of completion of w6ll
ForMa?,rl*le Wedsfl*3o�rtlisr'env otd0roo(-exaolpk 3@209-awl2@I M C4n5@mct oo to tht<foltociitrg;
10.Static water.level,beiow(op,of casi68: (ft..) Division of Water Rr-Ourmi,Information Pro essin.-Unit,
if wafer Jewel 1e rh aVel ed i'trj;';ase 114' 1617 htait.Sen ice Gctifcr,R•rleigh,NC 27699-1617
H.Borehole diameter..10" (in.) 24b.Fhr61mt od Wg1N ONLY: .ln addition to sending the form to the address in
244 a66 e,also sikinit a.copy of this fortu within 30 days'of completion of well
12.'N%rcll oDustritetiou.method: sonic construction to ilte follow-hlg:
{fc.huger.rulurl•.:wlblc direct Foslii etc
Division of Water Resourc&,Underground Injection Conti of Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27659-1636
13:w Yield(gpm) Met]ad of test: 24c.For Water Supply&Injection Wells:
Also submit olffi cdpy of,this form within.30 days ofconrpletion of
'131i.DisinfLettan,t,vpet Amount: cacti constnrction to the county health department of the countv.wlicn;
constructcd.
Fe rm GA1-t Revised.ALiSmA 2013