GW1-2022-05246_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD Far It Scmal llsr 01J11':
This form can bc`ascd.fiT tingle or Multiple n'clls'
1.w6q:Cootraetorhiforntation:
w:WA-MR ZONES
Stefan Smith FRONT: I nt•_}QRtPTION
WOW CvrA dDrNamo;
3576A (G fG
NC•iNcliCo=ctor-CcnifrbtionMui- cr Is.OUTER CASING(fareaulti-casrdwell-)ORLiNF.Rdfa tTicabkl
FRONT TO. n1A3TETBR. Tt1ICKNV-,5 AT'j6n L
SAEDACCO Inc 0 fG. 42 ft. 6 iq 40 PVC
rug ui}Nanit 16.INIVER'CASiNG OR 1111ING-f eotherma►c6,04 oxi r
FRONT .70 OLAdCETER Tlllt•KNESS' I 71t•17EItt1L
2,MM1 Construction Pier nlit 0:
l isrkllnppilir."ublr.xrtl parnritt(cc.Carrnry,Strtr�?,l�arinncr,Itgarb[eb rrr..J'
rt, ft. in:
3.V4 ell.Use(clipci..wcli 11:SCKEEN
Water Supply Well:. FROM_ P TO ( DrANIF:Trrt SLOT" Tn1CKN1.LS5' 1 AtATSRTAt.
C1Agliellilittal Min MpallPttblic 42 ft. 62 fi, 6 'in• 020 40 Stainless
Mkolhemlal(lleatineCoaling5upply) lelResidential Winer Supply(single) ft: fG
17hudustrial/Contntcrcial ®Residential Water Supply(shared) �o ROUT
TO <rATtiRtAr >d[YLACEAfEVT\iEmOD S'.V1rO11NT
�ltii Rtion 0 @.' 36 fL Portland/ben mwite
Non:W;'*r SupplF Welt: ft. rt
gManitoring Q�Rcco�rT}• dt. fG
bjed ott Wct':
13Aquifcr9cch6rg1 0Crouriftalcr Renwdiation iv.SANDIGRAVFL PACK fit a t rtieabt0
- . .. .' F'R014f TO 51ATMAG F:�1Yl_AC.f;�IF:NTbtr:rllOn
QAEimfcr Storage and Rccavew Milinity 8arrici
39 ft, 67 A, Sand 3
CA q uifc,i lest [754ormn rtct&MiMjgc
bV.V.rimcntgl Tc;-hnnlpgy ❑Subsidence Coi lr01
2(1:'DRILLi\G LOG(nllaeh ad+lilirrnal sheets if nece%san-1
OGeothernnd(Clnsed Loop) OTFacer YRONT TO OFSCItri 716}N[nrbr:4artl�icu,wi7 nicfi t;" "�i t1r.1
❑Cr othennal(Hcalin�:Cooling.Return) 130ther-(explain under 921 Retuails) 0 (4 30 fl sand
it. ft.
4.Date-Wcll(s)ConlpleIgd: 3 Feb 2022,«re11IU#EW53 ft, ft.
5�:Rra9l Llteatinn: fL (G � � p
Chemour ft. IL V� 9
Pactlit}blti'ncrTTumc Ficldy IDR ff opplicawc) ft. ft
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, fl fG �fIF+7ff548Zi1311 Pft)Cv�;•°�� (JR'
White Oak, NC, 28399 Plts3hidAd&i Ss at Citg. 44ZO 21.RF�6IASKi
Cumvberland
Cpltttt}' Iorce1 Nq.(PIN)
ti.l atitude and L6ngttifdc in glcgncsqrnk MWkeonds nr deiimufd, rocs: 22.f crtifraHano-
(li ivc111?�Ittr pig Jai7otistcllicrd)
34.839946 It 78.826035 �� �jLI 2/4/2022
Sipml' afCe�af,ad Well Contractor Dalc
6.Is(are)tlte-wNll(s): MPentiment Or T77 eltiporarr )fir rgnhib,thin form,1 G>rrhr tcrtlfy rlarar the wirlff r1 t}as f i wy)cvwtratred ur.aecordance
i;fth 15A NCAC 02C.010E or 15,1 NC,tC 0M.0209 lVell Coitstnection Sraradlarals and lhl is
7.Is this a rcpak in an existing Bell- Z1Ygw or ®No r o),r,fihls rrcriarllias&,ear prnrlr&•d ro Aw.os rfl mmer.
{f ar�is ix a rcl�rlr�Il aaur tme�rsCr urtt•�latstaatorlolt hr�mrarltur+marl ia�lr�larnc�aiaraari��Crha
rr rarrraraP�r P mmi2rCrarrrmra trrr.�v nc�.hrarJ r�Cl�da furuc 23.Site glagragl or additional well-detaili:
You may tlsC t1l a bacl:of this page to provide additional tsell site.d"Is''or n611
8.Rutnber of 1Ye11s&nstructed: 1 consuuction deiaiL You.mav also.atfaeli ad"ona[pages if it:Cessa'ry.
Fvaar iiralllinJelarktcn rara>-rimersri'iviltt.tFa�'G}'n'lfi rJad.srrnlararrstrirrriurr,vtar Cara
zte,vrir aar fi.rra. fi T MITTA L 1 ST T .TiONS
9:Toialtrell depth betatc land surfact 67 (ft.) 24a. Far All Wells: Suhvdl this farin within 36 days.of complaii6d of)yell
P'real)al*l,*liedux'dr3twPl+lev�nastjrf err^rY2ierrm P-T :00"trrNla�`llki)' cotvstnictiont4'Ike fplG,ying;.
10.Static water level below top of casi6w. (6.) Division of Water RLIources,lnfrirnfntiun Pz cns 1ng Unit,
1f miiYr Iful 4 abor!e ceasfaap: 1617 Mail.Sarviee Ceti&r,Raleigh,XC 27699-I4 17
It.11tirchoic diametei:10 (ia) 24b.Far Li fee-fine MIN ONLY: fn addition to'sending(tie fomt to ilia addrm in
24aabin'e also silbn►it a.copv of this.fotnt Within 30 din;s of completion of%V01
12.1510' cousfntction method: Sonic aottSlructiati ED the following_
(i.e.suggar.•rot�',calile;,direct push aid.)
Division of Water Resources,Underground injection Contrtil ProgrAin,
FOR WATER SUPPLY WELLS ONLY: 1636 ALM SeIrvice Center,Raleigh,YC 2769-1636
I3.0 Yield(kiln) ,)Method of test' 24c.For Witer Supply dC Inica'ion Wells:
Also subtuit.one copy of this furnl within.30,daysofcompletianof
13b:6isinF�titiun,ttp well cansinrction 6 the county health department 6C the counh wliaro
Amount:
constructed.
FoTn>G1F-( North Carolina Mpartment of Envirotutxtu aW Natural Resources—DTvii ion of\Maier Ro—lotrces Ray ked August-V 13