GW1-2023-02578_Well Construction - GW1_20230410

• i I
WELL CONSTRUCTION RECORD For Imcmal Use ONLY:
This form can be itscd roi single ar natltipk wris
1.Well Contractor information:
IJ-WATER.ZONES
Zach Thompson FROM TO DF.SCRIPtiQY
WellContnaorNattte ft. ft.
4478A fL fL
NC Well Cartmaor Certification Nwnber 15.OUTER CASING tfoe etuGl eusaifvsclls OR LILYER(if a' Flca6k
FROM TO DIMMTER Ttli'EMS5 NATERtAL
SAEDACCO Inc 0 . fL 1 35 ft. 1 2" (n: SCH-40 PVC
Contpiva•Nankc I6.4NNER CASING OR 77IBING kwaikerrmil cursed4oa
FROM TO DUA ETER YMC{NESS ALALTCRTAL
2.Wc11 Construction permit#: R. ft. 'b4
List utlajy+lkable well pennits(t r..County-shrte,Variawe,filrerdat err.)
R, ft. in
3,Wctl Usc(chccic`xell use): t7 SCREEN
Water Supply Well: - — - - FRom To D1.431.Mt I SLOTSi73 I TIUCHMS I NATERTAL
❑Agrfcultutul ❑NinicipaMblic 35 ft, 45 fL 2" 010 SCH-40 PVC
®Geothermal(HeatingXooling Supply} ❑Residential Water Supply(single) fL fL
®ttidustdalfconmtercial ©Residential Water Suppll•(shared) zit.GROUT
FROM TO NIATERML I ENIPL10EN-NT NEiTIOD S AMOt7T7T
❑Irii ttion 0 ft. 25 fL Portland Injection
Non Witter Supply Nell:
tt. rL
Monitoring pRccorrry
Injection Well: fL fl.
13AquifarRcchargd 00otlndwitcrRcracdiation 19SANDIGRAVEL PACK(if aripliubtay
'FRO\t ira MATF,RIM1r. R\rPl..t(:f�IE�T Nt_t'ri(In
❑Aquifer Storage and Rccof-ciy ❑Salinity hariicr, 30 it. 45 G. Filter Sand #2
❑Aquifer Tcst IIStormn;ttcr brtinaoc
ft. ft.
t7Egtcrimcutal Terhnotogy ❑Sitbsidcncc Control
:26.DRILLiI1G'i:oG(attach adtthioridskd!t if necesmn-i
❑ eothential(Closet!hoop) ❑Trlcer FROIAT TO DES CRWnON*((whr.hardac".v It'u+ckty M.gWn ra+o,nc.}
❑t.ieodtenuai(FlcalinglCoolin Return) ❑011ra(esplainuiiderlf2tRetua&) 1 0 fL 45 ft. Tan Silty Sand and Saprolite
45 (L fL Rock
4.Date Well(s)Compleled: 3/15/2023 Well ID#PZ2 3-0 5
fL fL
Sa,Weil Lacatnin: f[. fL �'.�-•
Duke Energy ft. fL
Facilily-IOlvocr Nmue Fkflity IM(Tappli:able)
ft, ft.
253 Plant Allen Rd., Belmont, NC,, 28012 R, fL
Pin sicafAddress_'City.and Zip -.2LRVILUMS'
Gaston Bentonite Seal from 251-301
(:aunt\• Parcel IdenjiM.1tion No,(PiN)
.r+h.lAtitude'and i ungittide in ftgreesiminuteslsceonds or decimal degrees: 22.Ccrtifiradtm:
(Iruell field,me I;W9uog is%Mcletd)
35.1972 N -81.0117 w /� ` 3/18/2023
rsfgrowrc o rccitifred Pkll Contr.(ctar Date
6.is(are)the well(s): EPernranent or ❑Temporary 4 signing this farm,i Iremb)•cerrlfe rliar rhr ndl{xl vtir(nrnl cxi++xlruclnd im rrcrorrlancr
frith 15A NOW 02C,0100 or 15+t NC,tC 02C.020t)q re ll Coorstructlat st Indards and rbrtr a
7.Cv this a repair to an editing well: EWes or MNtr rry+r o;rliir rccorrd lean'In en pmrlrled tn+tia rn*ll mt�tcr.
1f(f•ls is a repair,fill u+P k(toitr+nadf cvrum+crloo brjorrnrriort nor!�aplabt(bv nrrn+re of the
repair amler$?i rr+nurki ser ian ar cvr the back of this fame. 23.Site dhV1 am or additional well detaits:
You may use die bacb of this page to provide additional well site details or well
8.ltiumber of ivells constructed: 1 coustmelion deiails. You may also attach additotal pages if nevessary.
Foe+nnl{lple fgeerlotr_or aan-imeer nrpply wells(7h'LY mlth(lie s one ca(rsrrucrlar,you can
satrniit am jann. SUBMIA L iNSTUCTIONS
9.Total well depth below land surface. 45 A) 24a. For All Wells: Subinit di is form within 30 days of completion of rrr11
Form+dilphrivells construction to tile.following:
10.Static water level below top of casing: (It,) Division of Water Rea'nurces,Information Processing Unit,
if hater level is above caaag.ax"+" 1617 Mail Service Center,Ralci;,h,NC 27699-1617
11.borehole diam.da.8" (in) 24b.P'or jpfVSdon W h11v ONLY: in addition to.sending the fount to cite address in
2�a above.also submit a copy of this fount within 30 days of completion of well
12,Well construction method: HSA Lnstruction to the following:
(i_c.anger,rotary,cable,direct push ctcj Division of Water Resources,Underipmund injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Vidd(gpni) Method of test: ?tic.For.Watcr Supply&InjcctionWclls:
Also submit one copy of this f6mi within 30 days of completion of
13h.DisinfiTtiun type: Amount: well constmction to the county 61th department of the comity-when
cortstrtutcd.
Form GtV-t Noalt Carolina Dcpanntcm or Envirotuncia and Natural Resewces-Division of Watcr fteotrees Revised A gust'2Ut3