GW1-2023-02563_Well Construction - GW1_20230410

`;W^'LL CONSTRUCTION RECORD For triturnal use.ONLY:
This form can be used far single or multiple wells
1.Well.C6ntractor Ltfortuation: j
t.rc.��51 CER'LON 1S
John Eiseriman f'1tUM1 Ttl ur.S(TIMON
Well Commoot Kant` ft. ft.
ft. fl,
4439
NC Well Connac[orCcriificationNimber [S:Ot1TER CAS INGtrorktultl-eifsrd-46s)0R LINER,fif:a' tle:tbk)
MON1 TO DrA61ETPR THICKNESS \lATF.ntAl.
SAEDACCO Inc 0 ft. 35 (L'- 2" In. SCH-40 PVC
Con4it:mr[,nute WAN,ER CASING OR-TUBING{'eet6ciinal c owd-loti'0�
FROM 170 D1,43tFUR I TIQCKNESS NZATERUL
I'Mcll f'onstl'rletion Perruit 0:
LisisllappJlicandcu-cllp�ntai:at6r..Cnmrty.SJr:c,li'�riarcr.Irj2Cd'[aZeaY_i R, fl. [rt.
3, Vcll Ifsi'(aback well usc): M SCREEN
Water Su1ldy Well-. - -- _ - FROM -10 DIAMET):lt st•(► slly T1lICKN1Ns MATMIA1,
ClAgriculturdl r714iunicipaUl'tbP,is 35 ft. 55 tea 2'a in, 010 SCH-40 PVC
©Cteotlienatal(11e1tinWCooiins St:lpply) ©Residen0al Fluter Supply(single)
©ludusWillComotc,rcial ©Rcsideodal'%'atcr Supph•(slrlred) t?lc GROUT,FROM TO. MATERIAL Hd[PLtC£M1=1'T31MIOD C.LSIO[INT
❑ftri )lion 0 ft. 30 fL Portland Pour
Thou-NVater5u tip lyWell:
6dhlpni)oring pRccmc�' .
Recdoll Will: n. EL --
MAnldfcr lte.hargc IaQ; undn-alcr Rcoicki(ion MSANDIGIUMEL PACK'{if
mom in IVIATritrAI. R\[Nt.AC.r.�lk:\l'NFTr10U
❑ quifcr Storalgc ar.1 Rccot'cty,, ❑Salinity 13arricr 33 R. 60 R. Sand #2
❑A:r)nifer Test ❑SlortnWatce Ihainage
fl. fL
❑Expuinicntal TMinotogv 0Snbsidencc Cbldrol
1:2n,RR1LLl\G'LOG'fatlacti addltinnal 3hccls if ncce"ssrinl
[]G:otltentLtl(Closed Loup) ❑Tracer FROM To WWRIMON rtntar.ban[ucn,9-u,'oxt,t,pc,_sm f;,.dc.)
❑Geodlenllal(I-IeauntlCooline Mum) ❑Outer(explain Dirtier 921 Retuatks) 0 f4 60 ft, .silt/sand/clay
ft. rL
4.Date Well(s).Caulpleted: 2-3-23 Well l D#MW-11 !t. fL
Sa,Well Ltrcation.. ft. fL +u.. ii... .
Speedway ft. R. APR 1 0 7(1
'Qn•ac Facilily, rNante Facility IDk(ifapplicable)
4431 N. Center St., Hickory, NC, 28601
Sr-tV
Flr}skal Alddress.City:.and Zip 2L REMAR10'
Catawba Bentonite seal from 30-33'
Ccumti Parcel l[kni ittoalouNo.( kV)
Alp..I.irtitude and Longivalle in llegr ees/minutes/seconds at'decirnal dcgr ecs: i2 CerTiticrNnn:
(it aall 1-Wad,olrc lablplig k sJdlkkJa)
N W J_� --__ 2/22/2023
Si�rrJlurlo�f�+"': �:?,-�:�%:lfti're�`•:;,.-- Darc.
6.Is(ate)the"a'ell(s): XlPernranent or ❑Temporarn' e-c-7i+:mac j ie7r�Jnr[ted an Crdarrtrtlrc
mule 15AAICAC03C.'x:: -1:.:;4rei.;'ti A2M Well conslrrt7inn 5tonicTrefs[rndrlv[ra
7.Is tltty u repair to an existhig well: ❑Yeti or ®No rappoffiiv r[rr tvf hers f<•rn pmru&�1 r.';Jl:r.Nell air»rr.
If lhhS Y lJ rYikTlY,fill r,,;k17MM tun!evrlah rbe narnee Of rfie
repair mraer 82f rcrrrur&s serfion or on Me back-of thie form. 23.Site.diagran®or additional!veto details:
You may use the back of this page to.piovide additional well site details:or[i'ell
S.Number of wells constructed: 1 collstiuctioll details. You Inav ali6 anaclt additional pages if necessmy.
Forj#111lple arfexilvn orrJns-user suppi welfsONLY i4di r1jtastrmec4urstrimAwr,yeas eew
sunm&[rne form. SUBMITTAL.WSTUCTIONS
9.Total well depth below laud surface: 55 (ft.) 24a. Fdr All Wells: Subiuit this form within 30 d:n's of completion of well
For euslrlple 1i010(;sr rrtl deprbs rjdifJi rvnr le•xlmtp e-.@2(K7`[nul 2CvItu1) eonstmption to the follo%�ing:
10.Static water level below tell of casing- M.) Dirision of Writer Resources,Informatipn Pincosing Unit,
lfuvver level is tabors cast}(;:.eux^+" 1617.Nlail Service Ccater,Raleigh}NC 27699-1617
11.Borehole Mariam,8.25" (in.) 24b.rtiL ONGY: In addition to sending tlk fontt to ilia address in
24aab,ne. also sobtnit accopy of this fonu within '.'NO days-of completion of well
12.We11 conctt tetion method: HSA collstmctirnt to the following:
(i.c.�ugrr Aden,cable.direct paskafar}
Divisiott of Water Resources,Underground Inje,Will Control Program,
FORWATERSGPPLY WELLS ONLY: 1636 h1ail Service Center,Raleigh.NC 27699-1636
13:r Yield(glum) �ictlrod of test.- 2lc Fur Watcr Supply.&Injcctton.Welts:
Also subinit ate Copy of this faun widiiu 30 daysofMllpletioltof
13h.DisinfLctiou type: Atnnunt: _ wail constmction to the county hcallh depariment of Htc cormli'n•hcre
constructed.
Fanu GW-t Nonh Carolina Mpanmctu of Euv'ironmem and Natural Resources-Diviiion of Walcr R6mLrc,- Revised AlgttA N13