GW1-2022-07921_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD \ a� For frecriial Use ONLY:
This form sin be used for single or muhipk[cells
1.Well Contractor Information: �' v
[e-mail]
Stefan Smith FROM TO I DFsC•RtP11O\
Weil Cortrretat NArm ft !t
3576A
NC W01 Coninclor Cenifi ation Ntimbet `15 0l1TFIR CASING.for inohi=catr`d'nclls OR anolkabk
FROM TO DIAMETER THICKNESS I MATERIAl.
SAEDACCO Inc 0 ft. 25 ft. 6 in. 40 PVC
Colnit:un manic 16 INNER CASING OR I BING f&eulkral2l ellowd•loap):•
FROM TO I DIAMETER I THICKNESS M.%ITRFAL
2.Well Construction Permit 0: 0 ft. 180 ft. 2 hL 40 PVC
List all appilirtthle roll premitl(i.r.CoanhV.Stan•.i aarirturr.lf*6c i ele.) A. fl. in-
3.Well Use(check well use): IFSCRELN
Water Supply Wi-11: FROM I TO DIAMETER SI.OTSI7E 7111 1 MATERIAL
Oftricultural OMuoicipal/Ptlblic 180 1111. 185 !t. 2 in- 010 40 PVC
OCicothennal(Healing,'Cooling Supply) pResidential Water Supph•(single) G, it. i�•
CltndustrialfConimcmial C)Rcsidential Water Supply(shared) -FRO GROUT'TO t,IATFRInt. I 9M`PLACTMLNT METROD R ASiO1INT
Oirri ation 0 ft. 175 A. Aqua guard �Tremie
Non-Water Supply Well:
ft. ft.
®Monitoring ORccovcry
injection Well:
DAquifer ltechirge DUroundunicr Remedial ion 19:SAND/f.RAVEL PACK(J ►lkshlr
FROM TO lkl! 1RIM. EMpI.A('r:MENT MrTNOl)
DAgoifcr5toragcandRc�otrry. DSalinin Ramer FROM
A. 1 188 A. Sand 2
❑Aquifer Tcst OStornmatcr Dramigc f1• ft.
❑Experimental Tcchnolo&%• DSuhsidcacc Corarol
•20.DRILLINGYAG(attach additional,Beets Ifoeeemry
OG«oothenlwl(Closed Loop) DTraeet FROM I TO DFSCNIPTIONl+abr.haMnre+ptiRnrckN' ne6rr.Ht:
OG:othetmal(Neatiggtooline Return 001her(es lain under 021 Remarks) ft. ft.
ft.
4.Date Well(s)Completed: 12 July 202SdI1DRMWID
1%JL WWIIlAwatiun: ry, f1, AUG
l�2�2
Power Secure
»-�ilfulfFXi. A. d (�it(3
Facility';'Otct+cr Name Fac7ilr[DR(if appliaiAlc) It. ft. o t
�>JQI•3urJC-
1410 Coltrane Mill Rd. Randleman, NC 27317 Randolp, ft. f1.
Randleman, NC, 17317 Pln'sical Addmsa Citc.and Zip 21i Ri lttARK3'`'
Randolph Existing open bore hole depth was 101, punched
4a+nYt) ll.jrtelldeutifrcilionN(..(PiN) to
Sb.Latitude and lAngitudc in degmcs/minutca/seeonds or decimal degrees: 22.Certification:
(if cell field,one Iatlon$is st 11&s n) /t
35.910574 N 79.852492 W '-�yr 7/21/2022
Stria[ ofCcvfrdl4'c1lContrrt.for Dasc
6.IS fare)lire well(i): ZPennanent or LITemliorary M-signing this far.rr•I he•rrhr e•rnifv rhat Mr me11(s)rr is(weir)e-oniuuc'ted in mreordmcr
rcirh 15,1 NCAC 02C AI0)or I A NOW 02C.0209 uleY Cairomrtian Stamkrals and rhTr o
7.Is this a repair to an existing well: oVes Or ❑No ropp of rhis rernal line twen Vw0r:•d ra the strll rruner.
1/thfs Jc a relmir,fill ear Fnrium lied!ronsnu'rden Mforautriatr Anil exp(aht der narnre of rfir
relwir Lowder#21 rrmarkc prow ar an Mr hra•k ctfthis form. 23.Site diagram or additional%f ell details:
You may use the back of this pablle to provide additional well site details or%%-ell
8.Number of wells constructed: i consmIction details: You mad'als6 attach addilional palvs if imc'essary.
Far owitiple iglrelioll of wvl-ware•r tuplalp wells ONLY u lth rin,some comtrurrion,v(:u crin
.%wivnirstirforam SUBMITTAL ONS
9.Total well depth below land surface: 188 Ifs,) 24a. For All Wells: Submit this form within 39 days of completion of well
Fnrlwaliipk rrelis Nat rill de1n)tr(fdifferew(eamnp1e..?@200•cnvl 2010t)') eonstmetion to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
IfBvtra.level Is ahare ratfrrl,ate"a•• 1617 Mail ServicejCcntcr,Raleigh.NC 27699-1617
11.Borehole diameter.6 (in) 24b.For JOW111tn Well-ONLY: In addition to sending the form to the address in
24a above. also submit a copy' of this form within 30 days of completion of well
12.Well construction method: Air construction to the following:
0 e.migm rosary.cable direct push cic.l
Division Of Water Rccourccs,`Undctgroond.tnJcction Control Program,
FOR WATER SIIPPLV WELLS ONLY: 1636 Mail Service Center.Raleigb.NC 276"-1636
13a.field(gpm) Method of test: 24c.For Water Supply&injecthm Well.-:
Also submit one copy of this form within 30 daysofcompletion of
13b:UisinfiY7ion type: _ Amount: ,.veil constmclion to the county(hcallh dc1mrimctu of the county.wlxrc
constmcted.
Fonn GW-1 Nonti Cantata Mpannx-lu of Enairoamau and Natural Resources-Division of lili'ator Resovcr, Revised August'M)13