GW1-2022-07265_Well Construction - GW1_20220805

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WEL"G CONS'TROC'170N`REC0 D For ti mal Use ONVY.:
This forin can N'ascd forsinek or,multipk wdisf
]:��'c11 GSnfrilaor Informations
Stefan Smith FROM TO b s(mlptlo.4
11'ettCtiiilrtpot IIIw.
3576Af
NG Ndt Cotitr�ciur Certification Alritrlicr 1530UTER CASENG(foiTmulit r'seil aeOsT OR LiN£11 0 lkable)
FROM. TO D►�dtF,TER• T1trGKNECr = MMVITAL.
0 11.. 25 it. 2" id. SCH-40 PVC
SAEDACCO Inc
Cofiyi;uryirau� 163N11ER CASING OR UBING '"eolhermA ilincd46a I'
FROM . .TO DIAMETER MlICKNES4 -\r.ATERIAL'
2:WO Construction:Pernik#:
hill till amifkoblc r+ilrnc:7v rJ.li:r.GetiiUy:Stiih.•V•tri(aeie.TJa;'di`et err'.)
rt:. R.
3:�Vcll )sc(chest:vi`cll u3c); 17:SCREEN
Water Supply Well: FROM I TO TIMIK I;R :SI.OTSIM I 7111CKNIN-% 1 MATER►Al.
t]i�giiciilturaG OMunicip:imtbic-. 25 •It. 35 fl. .010 SCH-40 PVC
ft:' j,-
©Geothermal(Heatiogi ooling Snpp)' Mcsidential Water Supply(single): 1
0 industriaWdutuier ial OResidenlial Water Supply(shirred) sour..TO N1ATIiRIAL I r.frPI.+CI ME\T\rErnOD S AHOUNT
❑Itri'ation 0 it.; 21 ft. Portland �Tremie
itou-W:iter Supply%Vol:
®tilnnitoring t7Rccotcq• '
Injection,Well: n:• re 1,
QAq►ifcrRcebirge pGround+)htcrRcliicdiiilion 19SANDJGft(VECi'ACKttrdi'tlicabk) °" 3=; 4,•:
FRAM -' TO' -- .MATF,Rt.\L - P.uPIr+Ct NF;\'I Ml:rllol/
QAgoifcr$lortgciitWlk&ot•clp ❑SM.inittBumce: 23 It. 35 ft. Sand 2
❑rlgiitfcr 7cst Mtormwitcr Dminige:
n
ORxper mental Technology pslihsidem Confml
(IMRILLING'LOGli to additional itirNsaf ttcccsinn) s
EIG:otlieniml(ClusedLoop) ❑Tracer FROM To DESCHIPtIONrcvbrh,tnln%!o.xdl4ncktc a+n'wc.del
❑Geotitenual'aleatingX00 line Retuni)- 00tlier(ex•laii►utidirfr2l:Rema& o ';tt. 24 ft.: Silts
24 "ft.. 35 It- Saprolite , "'
4;bafu;Wcll(s)Cotigllctcil; 6-29-22 Nct1IDpM�-206 P -..
rt.' rL
5a.Willi.Gicaiiolm: . rt... h AUG0 � -
ALCOA fi:• ft.
Facilil;,'O»i><rNank . Facitit+iT)k(itappti::ibtc)„
293 NC-740, Badin, NC, 28009
phjskit,AddrtscCit}•,abdzip xIsRCMARI0V
Stanly 2 foot bentonite seal°from 21-23 feet.
Cnrm11,. l:lmcj ldaliil'i flon 140,(Pl%5
i
S1i:i,infutic and t on�nnsdc tn:dcgnet /mintitcslsccnndc tii ticcimal dcgt ccs, 22.C crtifie tine:'
tn tte1J 01s I:ttrldtig is sir<lic►iil)
35.407095 80.115290 �; 7/21/2022
`Y Sift• ofC Well Conductor Dale
G.is.(are)the+vc11(s):'.MPennattent • or' :❑Tcmporarv' it
!A s95aur l,,,a faun 1 a�rrhj ttrtifc lb(tl!hr girl!{s)frets{Ftrri cuitstnrcfrrQ Lt 6ccoYrlcner
n d',I V ICO2C(I(V of 1St1 A'C lC 0?C'6?01i)lief!CVJV:1"icat it Sriitkitrnl31rtiil llxv si
7.'L�thn a npatr(u an etistin vt c!L . ❑Y�h. )►r ❑N.ti:.' st\k�fd�tr irconlltar h.ci,pnyr 7rritl tri the u�It mr,rrr,
If lhfs is a/rjz tJr fill nu'�1?fi1t71 1Ytu falU771fftfatt ttt�0!YI11f101Ydatl Clplobt the owtute of the
rrllatr attrlir B2I ieujorki'.+.rfiir or ci i for batik of du farm• 23.Site diagram or additiona)n ell dkail3:
troll a)•Use tiw back'of tlds pa&to provide additional►dell:site del5ils or well
S.Tiiinber'of ticlls}tinstnlct cd 1 cotisiroLtioiiliciaiIs'. troll tn'li,ilso at aiiditioual:pabns if nei i ss:ir>:
FarmtilihateFnf�srinntrt:ncirl�'otrrtuppJr'�cirlls0�\GYslvtGihrr.snrnecotrsrruclloit,xotrccrrt
sabniittnlc/rrrrn. SUJJM1'f7.►L':(11 C7'[.1CTiQN�
9,Total:+retl.depll 6Clolr land surface. 35 (it.) 14a". L ar Ail �Vclls.,,:Subnut!}this,form nithir 3(I'd4 of 2oiiiptetion of iscll
Farmtthlplrj�-flshst;nlhlc�,flt.rtJrfl�(lr.r<tri(rsttttpfc'�:?La;pn•.ntul2G�lllfi) con5inlcnan'tnthcfolto+rin, i'
10.Static water Itt•el h'0mv top of casing;: bwislami of Water Re.ioueci.rj Information Pri"wri' Itnit,;
l saver le eM,rboi'e ciiiing:n�4' 167'l ilalfScx•iet Gems j-RAlcrrh,'tC 2i404617 '
1l:Dorr htilc diamrtci;8 25" "(in) 24b, Far inirctind4Ve11s ONI.1.c: in addition to sending the fomt to the.addw s in
24a kovd.-also submit li +.op) of, this•funn lviihin`.t6:d4s.'of'coinpletiowbf',iiell-
12_ ivclf constiiietion�oiethod:HSA em)simction tri ille followitie: y
(cd any r"ititan cable:dared Guslti cad)'
,Division iif.lVatcr Reiourtes,Underground.[njicUon Control Proh ram,
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FOR-W��TER.S[IPPLY`R'ELLS ODTLY' 163fi Iilail Scn'icc Gentcr,Pi ei>k.,N.':27697=1G3f
i4c.For Wiler S•J)ply'.k lnjcitiiili Wii s:
13;w Yicld'.( iin) �Ictlind-'oft csh
- rVso•silbinit 6m--cop).'Of this fonn.lvittun �)dajsoiionipletionof'
r
,)3h Dlslnf�YKutn t,pc: Amnunt� _- _ _ icdU coriMiuction to-the cpnnly licalth dcp;iriniait'of the•coiinhl.i•licre
cotistnlcicd.
Fonn Gl\r-1 rotih Carolina Depannt<nt oC Ein'irutuik ra aid Vamral Rcs iurces-tliriilon(Miter Resowes Revise eAugust`t113