GW1-2023-02729_Well Construction - GW1_20230411

WELL.CONSTRUCTION RECORD FarlMctnalUscONLY.
This farm can be uwd fui s ftln ar m0ip)c resits i 1
1.Wdt.Ctintrtetoe Information:
.tbrATE RZONIS..
Stefan Smith VHOJNI. tv DtSCREPTION
Wall C(rttlrwwt Mirt1C ft. R•
R. ft.
3576A '
NCNVellCuNaactorCertif:c-3tionNurrber t5;OUTERcALnNG(for,&ftyTc:iaelQRiaoORLTNER'(if'a' IR bkl`•
GROM TO I Draitit;TF..R TMM-NESS ML
SAEDACCO Inc 0 tt,. 15 (L 2" tL SCH-4O PVC
C(111v u l-Nallic 16 INNER.CASfNG OEt IQrBQNG,'i•eciihcrin_t etaacJ loiiii
FROU TO D_L.%-NIFTEER TRiCKNES.S HATERM
2:r,Yc1E Constl'uctain Fel•luit�: it. TO
LirYttllc�grlit'a$lcrscllprirab'sri_r:Cnurth•.Sla:c,tiyriamrr.Inyern'ertct,�l �, ft. ia.
3.Wcll use(chccl:well tiscl: t7:SC lt!EN
Water Suppflv Mleth FROM t TO owswTt:R I srors nr TmCxNFS5 I 'IATRRIAI.
Clrlgti`ultitrai Mlunicipal,( tublic 15 it• 30 Tr 2" in• 010 SCH-40 PVC
EMWthetmat dicidngtoolin Supply) Mes'ideittki Water Supply(single) ft. R. in•
©hldustriatfConmtcrcial ©Ri-Nidential WaterSupplg(sl.ured) -A&GROUT'..._, ..-
FROM To. NIATEt[AL HTrBLACF�FENT.lIMIOD c.tirtotrvr
❑hri ulian 0 ft. 10 fL Portland Tremie
Noti WaterSuliplyR,e1t:
l+d141pnitneipG Mccowfy
1Rjectiett well: (L M
prlquifdrRccliargc ptcoui►dnttcrRcn:ediatiou A9iS"D1GICAVEL PACK 0F.appli"Dtc1-` -- _
Gtilttl 7[} d1 ATP.ftrA1. RAIPIAMMENr NIMROD
❑A4uffcr:S(dragc;9nd Rccovcry ❑Salinity flaiticf 13 R. 36 ft. Sand 2
❑AgDifcrTcst p5tomitt ItcrDrtina,o
❑ExpzriweiV I Tcrhnotoge pSrthSid:rlcc.C4ldml _0 NR1Lfl 111G'I OG7allaetti'idt[l(inniel sdcelsif irececsaiil
Me6thennal(Clusett Luop) ❑Tricer I Frto�( TO DHseRtrnetNt�aar.n,rou��s.;ol,*n�rt . raa3n:.arct
❑Gaothennal(.Heacinj?lC acting Reunn) ❑other(eepluintmder421 Retuinks) 0 ft.. 9 (L Fill (silt, sand, gravel)
9 ft. 21 fL. PWR -
i
4.Date NYell(s).6n1pleted: 3-23-2023 Nyelt iD#HW-12 21 to 36 fL Rock " ' • ..-.
sa.well I rtCattl�lr� ft, rc APR 1 T 2023
Upper Piedmont Regional Landfill fL rt '
Facility,'On'ocr.Nam Facilely 1Dk(ifappliable)
9650 Oxford Rd., Rougemont, NC, 27573 ft. fL-
PIn3i",.ul dddiess.City:and Zip
Person 3 foot bentonite seal from 10-13'
Conui7 Mirrel I(Lili tieatlonNu.(P1114)
Sb.l initude and B a-nkltirda in 41c9t estminutcitsceouds nr dcdmal d%q'ccs: 22.Cepration•
(if uOf('lcld,one kblon'g ix grrlfieiaan)
36.327237 it 78.833647 TY 3/27/2023
Si�ru1' afCc4rifted�4'cllCaittractar,����f DOC
xl►l`nnattent 0C OTetuportn 17�•a;Cnhtg 1+rir f rrm:.1 hrrrhy i'ertilr'dhr r rhx rirlllsJ tsm(rtirrrl c'gr rrireted irr;rtexcrnJaace
4,ith 15A AVOW OTC,010?or 1.9A NCAC(X,0209 Well CounTorden SmaddrAs and rlau<t
7.h.th(.t a rcoai�Ea ad esistin�„"lt! MY�w or ❑No rofrr�,rrhis r,•c i+rf h.s bc.n+onwided na the rn-tl me,ier,
ff dllS:k n reJ�*.fW rna C�'oiw a'e1f AnAurlttcrinti btf rvw tzr:wi wuf,:(p&Wn the ownwe of the
repair•rmder 02i'rmnarkv smian or an the bru:C of elide ferny. 23:Site diagram or additioual nett Befalls:
You Play.use itie,back of this page(a'ptovidr:addilionat well site details.or tiell
8.Nutuber of wells cousceted: i couslmctimi details. You 11MV;d-4)atlaelt adilitiotnlf p IbcS if liccessary.
For iimikiple hon•rlon o ru
r rrwi-wirier supIdY n'eth ONLY u'irh rhestnngcwrstet�itioa,you eoa
sairnr$nnc farm. SLIBN[ TAL fNSTLTCTT M
9.Total welt depth bit w land 5lirfac r 30 ((Q,) .24a. Nur All Weil.441 Subruil this form within 30 days of completion of well
Forme+lilplciucUslisr(dideprbsifdlffierew(C.ratiple-.rE'.'td0'arut.2@1rk7) consim0ion(d the follonin8;
E".Static water level lleloe'top of curing: (ft.) Ui�.Nid'u Df Water Rer'nurces.Inforutation Processing Unit,
if uwer hn'el 6,Mow eusfgj iise"+" 1617 hiail.Sei'eiee C&fer.Ra d,,4,vC 27699-1617
It;Borehole diameter.10.25"/6" (ta.) 24b.Fnr Tuftcrinrl`L'ellt ONLt': in additioR io seuding.11ie fomr to the addfm in
24a koie.also Obtuit a copy of this faitit withiii 30 dm;s of completion of w0l
12.Well consttttetion method:HSA/Air constmetioti to,the following:
(i.e._-ogac rotas}',cable:direct push ewer
P.Milon of%Yater.Rescurces,Uttderuvnitd Tujec%lon Control,Program,
fOR IMM11 SUPPLY`BELLS ONLY: 1636 NLAI Semite Center,Raleigh,YC 2 7699-i636
13 Yield ?iG For Water Supply.&Injection Wcl1v:
.�Yield(gjim) fiicthod of tes(: Also submit one: copi' of this fdrhi tcithitt 34.daYsof cotnoletiott of
flab.Uisinfcet(uD type; Amount:
tvctl construction to the county licalih department of the coinh•where
consfilctcd. IG
i
Fami GW-t Mmh Carallna Np ututc D of£nslrowncrn and Natural Resouxes-Dirl;lon of Water Rmau Rei'ised AtguA NI I