GW1-2022-09139_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD For Imcntal Usc ONLY:
This fonncan be used rm sin8k or imillipk wcils
1.Well Contractor Information:
IY_WATLRZONN , . 7,7
Scott Hunt Jr. FROM TO 13FYCRIP1101%
%\'ell Coi+ingot t�alrnc.
4561-A ]SFROM TO DtAMET
NGWdlContraclorCcnificationTtuntbcr :OII TERCASING for ultimc irital"'wens OR Li TR Ha Ikabk
FR THICKNESS MATT.RtAt,
SAEDACCO Inc 0 ft. 35 ft. 2" in. SCH-40 PVC
Company Knntc 1ti.INNER'CASING OR`TUBING `eotbermatclosed.lotti
FROM TO I DLA:1tETER I T(OCI:NESS MAMMAL
2.Well Conspvction Pcnttit#:
fl. ff. tn.
Lift all apytlirahle Krll pPnrtils N.e.County.Sling.Ynriotrce.Ireectibn eir.)
ft. fl. m•
3.Well lisc(check well use): 17i SCRFJ N
Water Supply Well: FROM TO 111A1/F.TER I SIMSI7F I Tnl(-K%FNs I 111AURIAL
I�Agticultural t'IMunicipalftblic 35 ft. 40 ft. 2" i" 010 SCH-40 PVC
fl.i in.
43cothcmlal rticatingtooling Supply) 011csidential Nato Supvh'(single) ft.
®bldustrialfComntercial 011csidential Water Supph•(shared) FROMtOUT TO MATERIAL F:�tP1.crMENT 3irn1oD&AJIOGNT
❑ltti ation 0 ft. 31 h. Portland Tremie
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Rccolrly
injection%Veil:
0Aquifcr"Recharge l]GronndnttcrRcutcdiation 19:SANDIGIIAVEL PACK(if 14glIkahki
VRl1M T'O MATFRI.AI, ftMPl e('t:N F;'T mrtnou
QAquiferSiom and Recovvy ❑Salinity Hairicr 33 A. 40 ft. Filter Sand #2
OAgnifcr Test C]$Mmtit leer prlinagc ft h
OEV. cdmcntal Tnhnoto�• ❑Slthsidctrcc Cmttml
20.DRHAJ iG tiOG attach additional4berts ifiiecc.<an'`
DGeothenuutl(Closed Loop) ❑Tracer FROM TO DESCRIPTION ftebr.hnrdncii V.1vntek h' n ebre.Ht.
oGaothenuai(i{eatin&rEooline Retuno ®Outer ter fain under 021 Retnalles) See gbo a log it.
ft. ft.
4.Date Wcll(s)Completed; 8/23/22 Well m#AS-1
fl, tl.
51.Well Lncafhtn: ft. It. . `@,E m
Duke Energy ft. fl. S PP
^ O n,
Facilii�'.lOicrtcrNantc FaclB� tt)k{ifappliatilcj rt. ft. 1
8320 NC-150, Sherrills Ford, NC, 28673 ft. R. Irn'�r" esaty a „5-n F na
Pln'sical Address.City.and Zip -21:RChIARK..0V
Catawba Bentonite seal from 31-33,
Cantoy' 1'at el1&116606611Ko,WIN)
Sh,Latitude and I ingifude in dcgmcslminutcalseconds fir decimal dpgrecs: 22.Certification:
(ifwell field,one laitloit5 it;stdticient)
N W _. 9/18/2022 v
Signlutr,ofCcnfficd Wclf Contrnctor:M Daic
6.h(ale)the tvcll(): ZPermanent or OTemporory tin'.%igning this fowl,I heteb).eertift 4&v wire well(s)tsvts{via ej evatrturted in rxrardvnre
with 15A tVCAC 02C AIM ar I SA NOW 62C;0209 Well C.owsuvalon Staim1 ntls and ilur)a
7.Is this a repair ft)An 6isting well: OVec or CrVy of this rProtil hRt lwoi pnwfded to)he so-11 nnnrr,
lfthis it a seltAfe fill ear.t 7alm well nwisma^iron tnrfornwrlrn rind esplobt rite wrare of the
reiutir timirr 021 rernrtrAw see ion or rm the i)rert nfthh form. 23.Site diagraut or additional well details: _
You may use the back of this page to pro%ide addifional well site details or well
S.Number of wells constructed• 1 construction detaits. You may also attach additional pages if Iftwessaly.
F'or owhiple fajeetfmi fro neat-wirer vpt?v seeth ON1,V trirh the sane comtruorion,.ya'+rt cum
.wbmir one forrt, SUBMITTAL TMUCTIONS'.
9.Total well depth below land sur(ace, 40 (ft.) 24a. For All Wells: Surat this fonu within 30 daps of completion of well
For tttrililple n•clls list well depths if dip rent fcrmnpte•3@200•nrtd 20 100) construction to tits following:
10.Static water Ie.'el below top of casing: 01.) Division of Water Resources,Information Processing Unit,
lfitweer level is shove(ruing,ate"=" 1617 Mail Scn'icc'Ccnfcr.Ralcirht NC 27690-1617
11.Horchole diameter.8.25" (in.) 24b.For injection We11s ONL!': in addition to sending the fotnl to file address in
24a aWxle. also submil a copy of this form within 30 daps of Completion of well
12,Well connrnction method: HSA consiniction to the following:
{l.c.anger,rowan:cable.direai push ctc-)
Division of Water Rcsourecs,Underground Injection Control Program,
FOR WATER SIiPPLV WELLS ONLV: 1636 Mail Sen4ce,Center.Raleigh,\C 27699-1636
13a.Vicid(gpm) Method of test: 24c.For Water Supply aic injection\Vclls:
Also submit one copy of this form within 10 dapsofcontpletionof'
13b.Uitinfiction type: Amount—-�, %fell construction to the county Ihealth dclnnmem of the crnmh•.where
constructed.
Fonn GtV-t Nonh Carlini Dcyattnu-nt of Em roanrta atd Katnrat Resources-Division of Water Resources Reviscd August.?013