_Well Construction - GW1_20230315 (13)

i
WELL CONSTRUCTION RECORD a nos,Us ONLY
The Fonn can N.and for single or multipk sells 10 `
1.R ell Contractor Information: \ a \ � `
�+ 14.W'Ai[R lANf3
Scott Hunt, Jr FROM TO DkN'Rortios
Well C'omnNfAn Nann ft. ft.
4561-A
NC Well Cosrnwor Certification Number 11.OUTER CASING for T!Lhitasetl w(•Ilsl OR LINER i< icable
FROM To nr.(�IFtre TNIVKVF M%TFPLAI
SAEDACCO Inc 0 fl. 25 to, 2^ ie. SCH-40 I PVC
Conipwtn Name j 1e.INNER CASING OR TUSING_WorAerami ciowdaGIAD)
FROM TO DIA.NETSRf TR1C'kNESS I MATERIAL
2.Well Conatrttction Permit N R. tt, w•
list all apph,able wril perwsits 0-r.Crmrmtq..5har,Variance.1f#WNX rl%.J
ft. ft, ice.
3.Well I'we(check well ewe): 17.S('R[tN
Water Supply Well: FROM To MA141TER SIDT517Jt TNICk"Im MAT 11I.
❑Agr►cultural LiklunicipaVPublic 25 ft. 40 f 21 in. .010 SCH-40 PVC
OGeothermal Meating,'Cooling Suppl%I I_IResidential Water Su pph (single) fl' I, ►a
OhldustriaUCommercial I Misidenual Water Supph tsllired) I'GROUT
FROM TO MATERW. EMPtACTMENT Mrt1100 a AMOUNT
01trigation 0 ft. 21 fL Portland Tremie
Noe-Water Supply Well:
®Monitoring, ❑RCCot'en —
r dun Well: ft• �
i
❑Aquifer Rcchargc ®Gmnndwalcr Rcmcdi:nion It.SANDNA AVRL FACIC
FROM In MATT1RtA1. FMPI.1.(VV1v Vr V1vtn()n
[]Aquifer Storage and Recoven ❑tiahrom Rarticr 23 ft, 1 40 ft. Filter Sand #2
❑Aquifer Tcst ❑Stommatcr Drainage f6 1ft
❑lxpcnmcnlalTcchnolog ❑SrtlrsidCrocccoulml
26.DRILLING LOG(almtli additional iAMs if ncctssan
❑Geollienttal(Chased Loop) ❑Tracer FROM TO dESCRRi1pV 4abr,MwNava+,vdt n^4 elt.l
❑Geodlentnal I Hearin lC Relum) ❑OAlicr(Lv ain miler#21 Rematb) 0 ft. 10 ft, PWR
10 it. 14 R. PWR with chunks of rock
i.Date Wen(w)Completed: 2-7-23 WdlIDNMW-12 _ 14 ft. 40 rL rock
5A.Well LIICatkin: ft. ri.
Upper Piedmont Regional Landfill w. IL I j
Facilit%Ch%ncrNante FaetlihID#(if applic,iblei L R. —�
9650 Oxford Rd., Rougemont, NC, 27573
R. R.
Phssic:d Address.Cm.and Zip
It.R[INARILS
Person Bentonite seal from 21-23'
('oaten 1'.trtclldcnldlcaliuuNa iP1Nt
Sh.latitude and l.nngitude in degrecwiminutcwlwccnnds or decimal degrees: 2L Cerdlicatlnn:
(d well fold.mie lailmsg a stdlickutl fie_
W �C.�C.C� < 2/14/2023
signalaw of certified Well Co for Uaic
6.Is(are)the well(s): EPermanent or ❑Temporary M s 8 dos lam.1 herein-rerNfe that the well(sl ims(were)ciotassracted in mcordmttr
wide 1 SA NCAC 02C.0100 or 1 SA NCAC o2C.OXV Well COesttw icon Sita"irds awl dent o
7.Is this a repair to an existing well: ❑Ves or ❑No COPrOfphis nrrnM has bren Prm•hdnd in Fret well Pinner.
1f ibis is o remior,fil oat kmo oo n ru,,.,ur,ut mm rrtformutmot awl r cplunt dw,uormrr of rhr
repair ceder 021 remark%sr.tiemr c r,sin the brat of this form. 23.Site diagram or additional well details:
You may use the back of this page to pro%ride addiuotal well site details or well
S.Number of wells coma vicbei: 1 construction details. You rtna%also altach additional pages if necessary.
Fur"whop&ttijecrkm tar m(ml-water supple wells ONLY n',rh ow saint,constrwrmut %aw(am
srsbmir Rate fonw. SUBMITTAL INSTUCTIONS
9.Total well deplb below land surfisM 40 24a. for :tall N'ellx Submit this form wilhin 3U days of compkrton of well
For nmil*lt,wells list all depsbs ifdtlft,rt,m)(r.umrple-3Q200'and 2QlW) construction to the following;
Id.Static water Ievel beluw Ito to of cashir: 20 (fl.l Dh ision of Water Resources,Information Prvicewsing t nit.
1f wYib,!n 0„uho%e,asw r - 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.BareW►le diameter.to.62 5^/6^ (ice) 24b.For In r on Wells ONLY: In addition to sending the form to the address in
24aabo%e. also submit a copy of this form within V days of connAetion of well
12.Well rnwstrwction methnd: Auger/Air construction to the following.
(i c aggcr.retain,cable.direct push ex,I
Dhision of Water Rewourtirs.Underrrirund Injection Contntl Protram.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Senice Center.Raleigh,NC 21699-1636
IJA.Vidd(till hk*W off 24C.For Water 5upph .tic Injecition Wrllr:
Also submit one copy of this form within iU daysofcomplei ion of
IJh.Divrifmilion hPe Ameunt: well construction to the count health department of the counn where
constructed
Fonn GW-I Noah Carolina Depnrrm-m of Em tmimria and Nantral Resources Un lion of Water Rtsaroa Re%iced August Hal i