GW1--03534_Well Construction - GW1_20230519

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WELL CONSTRUCTION RECORD Far Mental Use ONLY:
This fora can be used for single or nwltiplc wells
1.Well.Contractor Information:
_:_I4-AV ATLR:ZONES-
Scott Hunt, Jr FROM I TO DFSCIUMON
We1ICor�ndvrlranrC tit. tit.
4561-A tit. fG i
NCNVeliCeaft torCettiframiont4uwbir 15 OUTER,CASING(farmut*&= fd W�614 OR:LWM Of stinflvLabkh
m0111 I TO I Dt&%M1 I TttICKNESY I MATERIAL
SAEDACCO Inc fL fI-
in
Captv:tay Namru 16 1NNER`CASiNG ORiTUBING' gnA wrural clasedaool►
FROM TO BENNIETER THICKNESS I AL TERTAL
2.Well Constr•pctirin PCfailt R: 0 R. 5 ft, 2" i1. SCH=40 PVC
lrsr a!1 a alirrr6lr.pmrPpeamits(Lc.Cnunrv,.Starry.,;trariarwr.Ti gbtq crr..l
R. fG
3.Well Use(ehccl:vvell asel: 17:SCREEN
Water Supliky Well: FIioN To Dt-AMETFIt SLOT 8171: THICICNIis I ArATRRIAI,'
DAgtkultural ONfuRICipalltrltblic 5 R. 15 ft. 2" in. .010 SCH-40 PVC
❑Geothetntat(IicatinglCooting Supply) ❑Residenffal Water Supply(single) fG fL
®Industrial/Contmercial ❑Residential Water Supply(shared) FROM—ROUT 70 AtAT'ERtAL ENIPLACEb1ENT htEfttoD S AMOUNr
131ni tion 6 ' ft. 3 fG Portland Poured
Non-Witter Supply Weft:
Pamonitoring QRecovc - ft.
Inject[on Well: ft. fl'
❑Aquifer Recharge QGroundwatcrRmcdiadon -19:'SANDIGRAVEL PACK(ifutdk-AbteV'
FROM TO 11ATP.RIAL R\IP1\CtAIV%TMETI10It
AAquifcr Stange and Rccovcty ❑Salinity 13arrict 5 R. 15 it. Filter Sand #2
17 Aquifcr Test AStonnnatcr thatiuloe
R, fG
❑Expctimcotal Tcchnotogy ❑Snbsidcncc Control
(1.1DRILL1NG'LOG'(allach additional slieemdlf necesurvI
❑Geothemtal(ClosedLoop} []Tracer FROM To DESCREMON fmbr.har*e"wr;1rnrkrrx.Vskwnsdrl
❑Gaotltenual(Fleatio#CuolingRetum) ❑0dier(explain under 921Reulalks) 0 ft. 5 ft, red fill dirt
5 ft, 10 - ft, cobbles
4.Date Well(s)Completed: 5-3-23 Wen Ej)f1MW-21 10 ft, 15 fG silty sand
5a,NIL41 L1►catbrn: ft. ft.
Crown Food Mart f4 iL (�
v
FacllitylOwperNmnc Facility199(ifuppikable) ft. ft. 1�5G�r.: ;•�. ;��,
300 Rodney. Orr Bypass , Robbinsville, NC, 28771 R, n, C1as •�, "h Vf,,'f
db•
Physical Address City.and Zip '.21.REMARKS''
Graham Bentonite seal from 3-4' bgs
Goaull' Parcel ldcailifie1lleu No,(PIN)
5b.Latitudc and Longitudc in dck tvevlminutcs/scerinds or decimal d rccs: 32.Ccr tiScatitlt►:
(itUell field,Cdw(among is salliciotd)
N R` 5/7/2023
sigmturc of Ccitifled Well conjo6tar. Dale
6.Is(m-)the-well(s): EPernument or ❑Temporary BF slgnhrg thir form,1 hereby ernify rhor Me hell(s)way(wemi corrrriucred ur auvrdmice
with 1 Lt NOW 02C,01(kl or ISd AICAC 02C,0200 Well Constrwrimr Standards and Awuu
7.Is they a repair to an existing well: ❑Yc.s or Moo cart of flak mrnrrl hers Nca nmrieW inti'v.emit!miner.
1f this it a repalr,till prat F'.1n4voj$•ell Coris-imcdca lttfionmrian twil mplaht the nature of the
repair arider,021 remarks srer(na or on ilk bcwk-of dips forirc 23.Site diagram or additional well details:
You may use the back of this.page.to provide additional weil site details or well
S.Numberof wells copstructed: 1 coustmetion details. You ntay also auachadditional pages if necessary.
Foentijhlpfelr*rlo)ioratkr-n'arersupplywells ONLY i-lilt rliesemiCQ sfrucamr,voilCan
sn6ullt one form. S BM13 TA L1NST T .TiONS
9.Total well depth below land surface. 15 ((1,) 24a. For All Wells: Subnrit this form wilbin 30 days of completion of Ivell
For paaNple wells list all drprhs(f d{f'rroa&.rarnple-3@100'arul 3ta[09 y con9tnictipri to tits following:
10.Static water level Delon'lop of casing: 10 (ft.) Division of Water Resources,Iaformation Processing Unit,
1/rarer level is above cusiag.ale"+" 1617 Mail Set-vice Center,R:tleigll,N!d 276994617
11,Borehole diameter:6" (in.) 24b.Tor Inieclion MIN ONLY: in addition to sending Ilia form to the address in
24a above,also submit a copy of this fouti within 30 days of completion of well
12.Well construction method: Sonic construction to thefollowLlg:
(i_e.auger..rduy,cnblF direct push.etc:)
Division of Witter Resources,Qndetground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service'Center,Raleigh,XI C 276994636
f 3a Yic1d Ggpm) 4letitpd of test: 24c,For Water SupylN&tniectfoti Wctls:
Also submit one copy of this furtil within 30 daysof completion of
13h.Disinfection type Amount: Well construction to the county i. lh dcpatimcnt of the calm),where
canstnictcd.
Farm GeV-I Nonh Caialhna Depanm enl of Envirounlctu and Natural Resources-Divisionof WarcrftL-,otr r, Revised August 2(i13