GW1-2023-00956_Well Construction - GW1_20230118

WELL CONSTRUCTION RECORD /� Forlt�staalUscDNLI';.
Thy fonn car be used for single or Multip3c wdis-
1.Welt..Coutrtetor Infortuation:
'14-AVAXERZONES
Chris Ru£fer \ FROM 10 p"CRtrsTtON
1t'cllCoritrrclarNanre
ft. fG
4223—A
NM ell CardmctorCcrtifi�ationNunitcr `�f t„/ WED 0.OUTER CAStNG`tfr)e*i ill e'asrd�sctlsl OR MER'(lf.a [icabk]
di 10 ota%mmt TFtIC[��IESS
FRO �rATERiAL
SAEDACCO Inc I n N I. 2071 0 rL 5 (L 2" 1n. SCH-40 PVC
Comp;ur)•Nawc- f kty ® :.E6ANNERCASIWOR,TrI9rNG(iiubewmylc&,cdddi'o'.t`
FROM TO DE&METER TMCt�:NM MATERLALL
�:YYc(t Caristruetirin Fet chit#: ��nr,c Ur►d
Lot`erllalpr7i�jrGlev,-c17penmtts(i_e:Caunn::Strcr,.lirria[rr- a.r.
rt.. ft. [n.
3.NVOt 11so(001C tr•cll rise): t7:SCRIM N
Water Supply Well: Fttom •t0 Dr,AMZ'Mft St.OTsL" TtuCrcNt s 10ATRRr,�r.
Mgrkultutal ClI6timicipcllrl'ub6ic 5 rt: 8.5 R. 2" io. 010 SCH-90 , PVC
Meotiteal(HeitinglCoolina Supply) esidential Stater Supply(single) ft. fL
rm ®R in.
©IudustriaUCotnmercial ©Residential Water.Suppl}'(sl>tmd) %tKGROUT: ...-
FROM TO. MA TERM ENIPLAC.MIENT AiEMO.D&.Lt1OMT
Elkiipation 0 ft. 3.5 iL Portland Pour
Npu-MlaterSupply Well:,
0MUnitoring pltcnovct}' (t'
Injection%ve1t: ft. rt.
MtliluifcrRcctiarge l7GroitrtlntictR.entcdiatiaa t9iSAN DIGRAVEL PACK'fi( plilb:ntic)> _- -
PROM 10MATCRrAl, 6:slPLA(I E14T IM_tnrtD
❑A4uifcr.Slori9c and Rwoi'ci}' CIS,ilinfty Bonnet 4.5 R. 8.5 ft. Gravel 30
❑Aquifer?csf CISlorn*ltcr i}riiva;c
Q"NTc.dp[cnlal Technotogy QSuhsidcncc Contol
an;DRR.LiT♦G'LOG t:illach'addhionat strcrts if itce imrvt
OGeotlrentml(ClasedLoop) DTracer FROM I TO R�CRrPT10Nlcataatx[�nc.+.�d;'nxkh unvaelst
13Gviliennal(Heating,CoolingMum) E101iter(ei3rlaittuuder.421-Remotks) I rt. ft,
ft. rl
4.Date*6lR(s)'Cou1p1e1ed: 12-14-22 Ypdt IMMM-24
'a. rL
Sst;Weil Imeathup iL See Gera' Notes
Republic Services ft. ft,
FaciTty,'On'ocr Name Faailit�-164 6 app(i able}. R. ft.
500 Landfill Rd., Mt. Gilead, NC, 27306 (4 r4
P16*kA i dd s5:Cit3•_and Zip <21t RenL.Rr:$
Montgomery Bentonite seal from 3.5-4.5'; methane monitoring
Ccu[ulp PYrrcCt lckrtlificalionNfl•(P411) w
51i.Isutitudranil I onj itad�in dcgrucs/miuutisJsmnds or dceim ll dcstccs: 2Z:Certiliratiten:
(its -11 lxw,ors
N W _Chris, Ruffer_ _ 12/14/2022
Sigwtur,iofCcitifrcdti'rcnCantr Wr Dafc
6.Is(lilt:)the;ivell(s)t $Permanent ur OTemporary 1i,•ar`srrbrg rhi Jum_I hereon•rerrily fhru rhr n•rll(s)t=y ftsrreJ eur_rin sled hr;fitzonlml,:r
ith 15.t A'CAC 02C.l]IA7 or i SA NCrIC fr;C;t]?pt]l{Ti it CnrrsPra tiNr Surrr lards ewid ilrrrr a
7.Is thiY a rttliairtu an ezistin„lt'ell: i lVas or ENO triprgfrhis rrcrinih isI ern istnrirled rtiltie.rrrll rnnrer.
(f rhrs:ls o n'JHiIP,fill r�u kri�}vr ri'�•ll c�errrnucNerrrbrforrnrrJon arrirl e.[p(ahr rh��PurrPrre of die
4jwir rtmlcr#21 icvnarJ sinclfari or on the bar.k:of flih fornf.. 23.Site diagruns or additiouat wetl detaiLu
Qa may use ilie back of this page to:proyida additional well site de!As.or ts'ell
S.Nuntherof hells eousimted• 1 construction defails:'You 11MV also'amc[i additiottaE urges if nCCCS9dty.
For tarhJlrle iro ihm orfit-m-wirer nrprrly wells ONLY irlrli rhe.srrmecrtustrrrrtiwr,your con
sarimil[mic�vmi. SCIBAiITTAL INSTUCTIONS
9:TOW R'611 depth Maw land surface: 8.5 (ft.) 24a. For All Wain Submit this funn within 30 days of completion of!Fell
Far Mahlple wells list all deDga lrellfferew(excwTfr-3@20i'wv1.2@ AW) eonswiction to the foUoniag:
10.Staatic,water level below tali of easin(,a ((1,) Did'don of Water R.vwurceis,Infiormatipn Processing Unit,
7Jnv)er love!Lv eLore eutitrr.urr"+" 1617 Alail.Scrricc Center,Raleigh,NC 27699-t617
El;tiorclrolc diameter 6„ 010 14b.Fnr lritecNotl NVe11v ONLY: iRaddition to sending fig form to the address in
24a above. also submit aw copy of this fonit ttilltin ^0 dm;s of completion of«ail
124 Well rnustmetion method: Sonic LoUstmcHan tbthe follM01.1e:
O_e.augtf.r6tar}',cnbl�direct push etc<}
Riyision oe Water Resources,4lndcrp muitd fnjection Control Program,
FOR WATER SGPPLY WELLS ONLY: 1636 AIA Service Center,Raleigh,NC27699.1636
13a,Vicki(dim) A'letltod of t4,st 24c.For Water Suttnlc&tWcet-rnu:Wct1v:
Also submit one copy of this fanu withitt 0:daysofcomplefionof
13b.Disinfection t3T q Amount, wcll construction to the county health deparitnent of the county where
canstnictcd.
Fe nu GRr-1 t`onhC=Hna Dep¢nmcm.of Euvirowvcrrl and Matrrml Resources-Division of%Valor Rimatrcm. Rcviscd Augmi'M 3