_Well Construction - GW1_20230315 (9)

1'VELL CONSTRUCTION RECORD For Internal Use ONLY
r Th6 form can be used fiw sinKk or rnuhipk"ells
1.Well Contractor Information:
14.WATUR ZONES
Scott Hunt, Jr FROM TO FIF_N ltlr'TION
',gent('0tttrtgor Naalr 14 ft. 15 ft, rock fracture
4561-A R. ft.
NC Well Contractor Certification Number IS.OUTER CASING for tnuMi Cased%cIsI OR LINER lif Mc&It
IIIOM TO nttNFTFR THr KcrSS NAITRLAI
SAEDACCO Inc 0 IT, 14.5 ft. 2" in. I SCH-40 PVC
Campo)Nate W VDIM CASING OR n1IUN_G 4motbermal c -lowl
rROM TO DIAMETER - TIII('ASF.SS NATERIAL
_.Wdl CoOmineden Ptetdt
fisr all appfirable well perwits(ir.Cotmrte.5tmr,l'nrin,n r.Irfecoal Fir.! -- —
R. It. a.
3.We6 Uee(chet-li well u%vi: 17.S(IMN
Water Supply Wall: FIIoM I To DIAMETER MATTS177 TmCkNIMS M.xtrVIAL
OAgricultural ❑MtmicipaUA►blic 14.5R. 29.5 R. 21 is. .010 SCH-40 PVC
OGeotheroal llieatingrC'ooling Supply) ❑Residential WalerStpph tsinglel R' R in,
OhndusiniKommercial OResidential Water Stpph (shared) IILiOM�� To MATERIAL EMFIA(1 MgNT MEIA00 E AMOUNT
❑lm tlon 0 IL 10.5 fL Portland Tremie
Non-Water Supply Well:
®Monitoring ❑Recovery _
rojecl on Well: R. r4
OAquifcr Recharge ®Groundualer Rentcdi:aiott 14.3AN YtLP IN molk&b)
M M STFRtat. FMM..0 V%lr'%T MFTWm
OAgaifcr Storage and Rcu men ❑Salinity Harder 12.5 IL 29.5 ft. Filter Sand #2
❑Agnifcr Tcst ❑Slommatcr Drainage
R. R,
❑Experimental Tochnology ❑Glhsidencc Conml2411.DRILLJK LOG fetlock eauil sheets N ttaceawN
❑GeothemtallC'InsedL(wp( ❑Tracer FROM TO DCSCRIFTIONt,06r.Ysrdwva, ogor,prai—o'c-it,
❑Goothetmal 11-1caun Cooling Retuni) ❑Other(explain under a.1 Rennadsl 0 R. 10 fL Pwr
10 IL 29.5 IL rock
j.Date W'ell(sl Completed: 2-7-23 Weil Iostmw-ll
h. R.
5a.Well l.trcatitm: IL - R. -
Upper Piedmont Regional Landfill tt. t tt I t !
FactlnyCktncrN;noc Faeilk)TDN(if applicable)
9650 Oxford Rd., Rougemont, NC, 27573
Plvomcal Addtcss.Ot,-and Zip 21.REMARKS _
Person Bentonite seal from 10.5-12.5'
COutsh PatcelldenhirwallonNo i PIN i --
Sb.Latitude and Longitude in degncslnnimrteslseconds or decimal dtgives:
22.Certification:
(,1"cl:[,cIJ me I:o Int,c,"rdfiekali
N W �C�w J ' 2/14/2023
Signature orCemirtcd Weil CovezWr Daic
6.la lam)the wellls): XPermanent ur JTvrnptorat'n 1h,i axe g g dice form.1 herrbr•rertift•that the wr1$s!ws(weer)carwarsrcrrd or arrordmtrr
with f SA NCAC 02C,0100 or f SA NCAC o?C.0200 Well Comirw new Smadards and that it
7.Is this a repair to an existing well: Yes or ®No cape of fait word has form prm•idrd to Ar wrll mvnrr.
If shii is a rrpasr,fill,cat 4ne,ww Kett,.rrupu,lr.ra mformamtti awl rtp(aot dw wtrare of rhr
repair vender I11 rrmarks m7mrr ar rs t the brat of this form. 23.Site diagram(or additional well details:
You may use il►e back of this Isage to prottde additional well site details or welt
8.Number of wells constructed: 1 construction detach. You Ina_s also allach additional pages if nevessan.
for m diolde otin rkrn ca ream-worrr"Vph welts ONLY ovlrh the restre(onap trcNua Wit ran
,dwor-w fi-m. SUBMITTAL INSTUCTIONS
9.Total well depth bchrN land mrfaee 29.5 lfl.) 24a. For AN Well Subnat this 1'onn auhm 30 dats of completion of well
For mahtpfe wells hit all drprhs ifrt*rrru owrample-3@200'and 10 NNr) consmiction to the following
10.Static water Iesel below hop of casing: 15 (fl,l Ph ishin of W ater Resou Tres,Information Processing I nit.
t1 tow.;r,r1 r,ula cr,asv+( 1617 Mail Service Center,Raleigh,N('276"-1617
IL Borelsolc diamrter:l0.6 2 5^/6^ f 1L) 24b.For Inkction Wells ONLY: In addition to sending the fort to the address in
24a abo%e. also mkimit a copy of this form within 10 loss of completion of well
12,Well construction mcKhod: Auger/Air construction to the following.
u c auger.roan.cable.direct push cw.l
Dhision of Water Resources.Underground Injection Contrnl Program,
FOR WATER SUPPLY WELLS ONI l: 1636 Mail Sen ice Center.Raleigh.NC 21699-1636
I3a.Yield(am)_ MC1hnd of test: 24c.For Water Supph c4 Injection Wells:
- Also submit one cops of this form to ithin 1,0 das s of completion of
13b.Disinfection type Amount: well consiniction to the county health department of the count.v where
colaanicied
Fonn GW-1 North Carnluta Depannwni of Em troumwm and Natural Resources-Dn ,on of W'ancr Resonrees Re,used Aug Ust 14od?