GW1-2023-00955_Well Construction - GW1_20230118

WELL CONS'FRUcrION RECORD Far lMcrnal Usc ONLY:.
Tip,form can be aged foi single or multiple wdis-
1.NW11 Cnutrrtetor Information:
Id:.AVXTER ZONFS
Chris Ru£fer FROM U, DF'SCRIP iON
XV01 Coritrrclor Narog R. ft.
4223-A RECEIVED
ft. ft:
NCAVell ContractorCcrtifiationNiunber 1S.,OUTER CASING c Wvi ullk2wd wctM OR LiNER{iftt` Ucatki- :.
TO
SAEDACCO Inc
JAN 1 8 2023 0 FRONT ft.. 5 fL 2 tAMF,TB -in. SCH-40 PVC ntAL
(mrrp;uryNauµ ,• 7 �. UM MANNER CASING OR=TLr®ING.kgoikirttAcluscd4oi'i -.
Ii1�Qfilfe�.7DD� P` FROM To DrAwlOR TMME& NIATrRLLL
-2.Welt Construction Pr ralit ' R, ft, in.
Lis p+tilairp7icublauc1lp6TWts.0-.r,.Cawtg,.Strrc,V,rriarce,ff*C11Prr-,:J' -----------�
3:Wc11.Use(chccic well fist): -17.SCREEN
WAterS,uppLy Well:' - FROM '10 arAm trim; st,crr5tzlr I TNICKN"-s I NIA-mRtA1.
rJAgt<cnftuml_ 0.NitinicipaliNbiic 5 fL 20 ft. 2" in, .010 sex-40 PVC
Mc6thennal(Heatingtooliog'Supply+) DResidential Water Supply(single) ff. ft.
®IndustriallConimcrcial ©Residential Mor•Supply(shared)' ttl GROt!f:..._.
FROM TO. MATERIhL ENLPEACENMNT 3WnIOD&.L\IOUNT
Elirtipatian 0 ft. 3.5 R. Portland Pour
Neu-Water Supply Wgit:
1. R. ft.
l6t9ni(orinG QRcc(wcty — -
Inieclion eb• to ft
MAtluifdrRef:hargC M'SAND;MILVEtLVACK-(ir: ldiiabtel-
FROM 7Xl 11A7rHt41. E?NIPIACtLLE11YHl1l1011
0X0uikr-Storagc aral Recovery 13Salinfty Hairier 4.5 ft.: 20 R. Graves 30
C]Agnifer Tcs(. ❑Stotmn;ncr t}r;iia;9gc fi.. fL
bExpctfmcnial Tcchnotoliv. Clsosidcacc Canimt
2n:DRILLING LOG(attack additionil sdcrls if imccsmrsi'
OG;rltlrcmml(ClasedLoopj t)Trlcer MOM 1 TO DrSCRIMUN,fcobr,hanfnea>it44+ictin N�C.dct
EIGmtheitual(fieatinWCooliui Return) til]ttter(explain under.A.'I Retuarks) :ri I ft,
fL fL
4.Date Well(s)'Coniplcted: 12-14-22 Well iD#MH-23
Il. fL
$r!:Well Gucntillu: , L See GeM' Notes
Republic Services ft. ft.
Picilhy,givnermme, Ficilily 11M(ifapplicablc). R. ft.
500 Landfill Rd., Mt. Gilead, NC, 27306 {p tL
Phyttal'rldd ass City_usual zip 21:REMARKS
Montgomery Bentonite seal from 3.5-4.51; methane monitoring
Ctruuly PircclIr1nntiri4iliouNo,(PIN) w
ih'.LMitudc an&Lcingftudc in degrtcafm1mtt61secoads or dceimal dcgt : 32.Certification:
(Ifirell faCld;pig L+L1riuglgs+rlti iva?
N w _Chris Buffer 12f14f2022
Sianiturc of Certified INcH Co nlr3ctGT Dafc
6.Is(are)the:Lvel1(9):.MPcnnaneut or ❑Temporary I,r.gning.&Li farm..!hereby cerrifr 1�iar ihr n•rllfri tsar{xiteJ eornIme-red irr•zexonh:acr
Weh IM NOW 02C.(1 0 or ISA kc'1 k.o200 well Colrsfirir:riar Sk+rxkfrds rgicf elute a
7.]�,thfwa rejiafrto AnctistingAvelli EALY Or ENo rqj Lrpffhbr iecrinibrighccn Pmvi( d rnihr ur ,rn'v+er.
if MISiis a 0o itv+1i'll cw'b7 lfr+iarl brfcrruwv`1c+anti c uphihi rhe.rwrsre of tlia
iYln:ir racier dr2l-rcma&, srraiun or on die barL of diiv fprnc 23.Site di4tram Orl additi0alll well detaib:
You May use Use,bath of this t>?fiz iti;proeidcadd9Gonal well site.details er%iell
S.Numberof wells eousttueted: 1 construction delairs. S'ou in iti itlsb auac[i adrGtiottal pages if 1lcr:�sarv.
O'l Forkiihip!e kdeeMM nrui-n'arer supi+ly well>O+NLY mifii nce snrcfgrrr+estrnrtirur.-Yc:rcon
s+pinSra+ic Jom+. SUBINITTAL iNSi C)CTfON4,
9,Totil wal ilelith helmv land surface. 20 (ft.) 24a. For All Wellri Submit this Fann witlliti 30 daps of completiou of Ivell
For+reshiplcreelfs'Ilsr all deprbsirdf,{1emiu(eternlpf,-.rre'20'w1fl.'2@IM) eon5tmctionto11tcfolloning.
10.St the water level beluw tall of casinla MJ Division of Water RmouwLi,Informittlaa Processing Unit,
eruler trvr713 above e�uaiag,asc"+" 1617 hfail.Ser •ice Center,Ralcigi,W 21699-1617
IL Borehole diameter.6.. (UL) 14b.l'or Ailtx.tian WRIb ONLY: In addition to sendipg the fomi to the addles in
244 ab&e• also submit a r djh,of this font within 30 days'ef.co_tnpletion of h'�ll
12,Well coustmetion method: Sonic Lonsittletiml to the follotviug!
{�c.aub•cs,•salary,.cable,direst push etc.}
Ilivislait of Water RCy4urc6,Undengrottitd fnjedietn Control Progrant,
FOR WATER SUPPLY WELLS ONLY- 1636 Mull Service Center,Raleigh,NC 27699-1636
13a,Yield(90.0 \•diod of test; 24C-Fat'Water supilly&twection wells:
Also subiAt one copy of this f6tu !titbit►30;days of conlltletion of
136.Dlsinfcc on Q<pc: Amount- well construction to the cauntp hc:dth depaornent of the coanty wherr
constntctcd,
Form M-1 NonhCamMia 1Aparr.=l.of Envirosnlent and Niatriral Resources-Dicu Ion of Waler ltMatreE, Revised AuguA2011.