GW1-2022-05193_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD Fmr_IlacrnnlU'scl3NL' :
Thi's form can bc'ascd.Crrr.s Nglcor multipk weak'
1.1'Vell:Cantracto r Inforntatiott:
14.%FATE,R 20N IS
Robert Miller FROM 'rO. nFSCHIPi"IOY
W011 COa7m%ttoi-Nammc ft. fG
2675 O. fG
NC Well ContmclortcnirrcationNnarJier ts:OUTER CASING(6rr'mu1,l-cm4rd"11.1)OR LINER fif a e flcahie)
FTt011. To DLM1RIET61t TitICtCNBS4 NfATERIAL•
SAEDACCO Inc 0 7G. 63' fG 6" �q, Sch40 Pvc
Canap;uq:Nantc %.INNER CASING OR 1'OBING I;eotdcrmnt closed-lwi
-FRO1f TO DLM11tETEIL TDiCKNESS I NUTERUL
2.well Cowgruc00'6 Oct'Rlit l'r: fi, ft iat
Ir,'rt kll rrl�'fieribfe v-elllteiatafts ll,a Coamfa•.Sti"e:e;-Ynriarccr,.Trf�b'erd rsr:J'
rt.- ft,
3.Wc11.Talc(check.ivgll rise): 17:SCRtiEN
Water FROM 1'7O DIANNRTF;F[ SI,OTV17Y, TritCKNFJS I•NTATFRiAI,
9d, IfilTll Rcll:. 63' ft. 73' ft. V im• 0 .02 Sch40 ' ' Stainless
l�rkllT(cttltii7al C]IbTtmicp4'llllfi%li(ic
®Geothctmal(Iiewingtooliog Supply) t;IResidential Water Supply(single) ft. ft:-, 'm'
®ludustrial/Conmiemial ®Residential NVater Supply,(slrtred) 18.GROUT
FRO,IT. 70. "TATERUI: 1'NTPL\CE110TN1171HOD&AmouNT
O1rii'ation 0 ft. 57' (G Portland trimi
Nov-Water Supply,Well:,
n.. rt.
QM01114orin-, ORecpvcry
Injection Well: ft. fL
QAt)uifcrRccharrgo Ndr6utidvOlcrRemcdia(ion 19.SANDIGiUVELPACKIttara]]auh,tcl.
'PROM" ' Tad 1TA'rFHt.M1 i'. F.1t Y1�\Ca�11RYT\71_"F'nO7a..
QA[]uifCcStoiagoea lid ReCovely QSalinityB;Irticr 60' 'ft.. 78' ft. Silica Sand 20/40
❑AquitcrTest Q51omm ttci 1)mtnigc ft. ft.
Q i lctiruenial`Ihhnot0� E1SUbsidcncc Ca74ml
20.DRILLI\G'LOC(nttmeh adititionnlsheMf if rxeessnrF't
ElGeodtentanl(Closed Loop) OTrlct r FRorT. T%} DF CRrPTiON imisn l nnfuc i.a t;'r Lek t K: 7r1 <c.ear l
❑GL*othennal(Headikge iCoolfng,-Return) ❑Outer("plain under 921 Retuaiks) ft. (L
ft., fL <" -
4.D4e'WeR(8)f.6mplttted: 3/8/22 Wt11IIafaEW-5 K^ V .""•
ft. ft.
5a:Well Location:
ft, fL l� .:ns7 Und
FlaoEl t}a01%tn rNnmac Facnily!Dm(9Capplic able) ft, ft. r�`��.Q11
1248 Bill Hall Rd, White Oak, NC, 28399
P]Q sscal Ad&ui s'03t.and Zip 21.KEMAHai$
Cumberland Three feet bentonite Seal from 571to 601.
Couu�' Parcel Ideanikauon No.(PP4)
b.1�titircic aril Iaingpttle it tictitceslminutrslscconds nr ticcitnal gr ccsi' 22.Ccrtifcatiun:
(if rti 1t tkit]�ant%f;>t�7ee g i+rtfi7ck'ol)
N 2/17/2022
Dais
6.Is(are)tarea'ell(s)t MIr'erniancot or LlTiniporary HX.signing A*furnr„1 hereby evififp aliut Me Trllfr/vary(Were)cururinrrted err-deenrrlance
mial 15A NCAC 02C.0103 or IJA NC+IC-0X,'G2l,0 flat Coititracrioir Swalar4s crud ilarr a
"I.4 this a rtl►air ft)an euttint;)i'cIL 3YLs or ®No lines Meer pr?rrrided in ibc sirll maser,
1f'bts:IF o mpolr,flf Ayr kx;l N well nnAsinfeikin bvorrw.nlon mul e plrabt rbe nnrire of(fie
nc'�w5ir riarcltr3 1.rrivar{:r Srridon tar•im rlic.brxk❑f this fnrur. 23.Site diagram or additional Mill details:
You quay.u4c-tlic'back of this page to pro\;ide additional well site details,or%sell
R.humUir of M1%tills ionstrnrted: 1 cons(metion'detaiL3;'You 11my also:affaclt additional pages if n:cessary:
For s aNy'vre 1,Veei,ut cy PQMq purer ppAy,wills ONLY 1d1rb dae mma rnirstrrrirJon,,}'oY c t is
sa�imlrane/aria. SUBMITTAL iNSTLTCTIONS
9.Total ivellitepticbeGriv land Mirfnee: 781 ((7,j 24a. For All ��'ellst Suhtitit this fonts within 30'days.Df cnmp[etititi of%well
Foranul:,IpJa lfd$itresit%exmij7e-7@209'cuul,2@1197 constmetiOnto(he folloning;
10.Static water level Below top of casing: ((Y,j Uivisien of Water ReSWrce.'I,lnfnrmatibn Prucessinp Unit,
If%never level is above a asfgw use'`Y" 16b Stail Semiec Loiter.Raleigtl,INC 2 7699-16 1 3
IL Bnrchote diamcke;10° (in) 21U.Ft)x jB j��i t�clay ONI.1': In addition to sending the fomt to thc-address in
24dal?oee: also subtitit a copy of t➢tis f01111 Within30 days"of Completion of%well
12.Well'constructiou method: Sonic Constriction to tits followine:
ti c.auger.riFiary,'cnblc'dined Fusk etc.)
'Division of Water Resoumes.Underground Injection Coutr6l I'roQratin,
I'OItWATERSUPPLY WELLS ONLY: 1636 Mail Service Center,RAleigkNC 27699.1636
13:1,field(gpm) Method of test: Ztc.For Water Supply Bt injection Wclts:
Also submit one caps of this form within 30 days of complet ion of
13h.Dlsinret�t on,fvpi: Amount: %%•cfk consoruction to the county health dcpartment of the county.whem.
corlsirtictcd, �
Form G%Lr-I hflnh Carolina Degamrenr of Enviroltnrm and Nantlal Resources-Divii ion of Water Reowces Revised August'2013