GW1--03537_Well Construction - GW1_20230519

WELL.CONSTRUCTION RECORD �� For[menial Use ONLY:
This firm can be used for single or nrultipk wells
1.Well.Contractar Information: \
`I&:.WATERZONES
Scott Hunt, Jr FROM TO DPSCRiPi1ON '
Well Coritrador Nanie R. R. I 1
4561-A R. ft. , 1
NC Well CanaactorCer1(:ration Nurturer .IS:OUPERCASiNG ft'br iun111 sEd'riells)OR LINER MO.t)cableY
FROM TO DIAMETER THICKNESS' MATERIAL.
SAEDACCO Inc 0 ft. 4 ft.' 4" hi. SCH-40 PVC •
•
Coatp:uty Nature 1(.INNER CASING OR;TUBING'tEeoncer mal clascd-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Pcrwit#: R. fit. ht.
Liss efl app!fcabte u,rlt pemrfls(Le.County.Stute,Variance.IIFarem,ere.)
ft. ft. in,
3.Well Use(check welt use)?
I7:SCREEN
Water Supply Well: FROM TO DIAMETER St.OTSIM T1IICRNt iS i MATERIAL.
❑Agrttultutal , CIMunicipaliNblhc 4 ft. 24 R. 4° in 020 SCH-40 PVC
®Geothermal(liieating;Coolilg Supply) ❑Residential Water Supply(single) ft. re iR,
®industrial/Conurtercial ❑Rcsidential.Water Supply(shared) tee GROUT _. _. . ,. _
FIiOSf 10 • MATERIAL EAIPLAG'EltIT.YT\iE'iIIQD&AhIOUNT
❑urination 0 ft. 3 ft. Portland I Poured
Non-Water Supply Well:
Monitoring I2IRccoccty ft. ft.
O
InJedion Welt: • ft. . rt.-
D Aquifer Recharge ClGroundwatcr Remcdiation •t9c'SANDIGRAVELPACK(if:yipIkabte)'
FROSt To MAT$RLU. EMPLACEMENT METHOD
°Aquifer Sforage and Recovery ❑Salinity Harrier 3.5 ft. 24 ft. Filter Sand #3
❑AgnifcrTcst ❑Stornmatcrinagc
R. ft:
❑l:gperinicntal Technology IDSubskdencGControl
'to'DRiLLIN( LOG(attach addltiunat slicedif heeesssr l •
oGeothemial(Closed Loop) ❑Tracer FROM TO • DESCRIPTION(wbnhanlacn,wR'nkktrpe.5r. n tite.ar)
❑Geotltennal(Ileating)Cooliue Return) ❑Other(explain under#21 Remades) 0 ft. 10 ft.. cobble layer
10 ft. 24 ft, silty sand '
4.Date Well(s)Oinipteted: 5-2-23 wren ID#w-18 ,� , .-._„
rr. rt. --d._
5a Well Location: ft.: rL , ....c •,tyti I `9 'I
Crown Food Mart _ ft, f), MAY 1. 9 2023 •
Faci1ity..tcrNume Feclhty IDk(if R. fit _ - 4
Info rtir,3-.�m 7r:`rq,..,�� LrlM.
wn
300 Rodney Orr Bypass , Robbinsville, NC, 28771 • ft, ft, I-"Q 2
012.
. P1n3ienl Address.City_and Zip '.2 i.REIGARKs -
Graham Bentonite seal from 3-3.5'
•
• Canuly Parcel Identificalion No,(PIN) •
Sb.Latitude and l.(ingitudo in degrces/minutcs/seconds or decimal degrees: 22.Ccrtifieati+Im
or via Aoki,pm;raS1oog is 3mi litienl)
N w c5Ce eze 5/7/2023
Sigrnturc ofCcitilicd Well Co r Dale
6.Is(are)Ibewell(s): ZiPerinanent or DTemporary By.signing this farm,I hereby eerie":thus Ibe.re11{.5.)war(ken,)constructed in accordance
with 15A NCAC 02C.0100 or LTA NC?IC 02C.0200 WI Construction Sraadards and Aix a
7.Is this a repair to an existing.well; ❑Yew or C8No crpm Of this rcrncri hay New pmrirkd to the.nrll miter.
if this'&'a repair.fill one kooks well constnrctloa hr/orwxrrlat and sprain ruts twrare of rite
repair angler PI remarks xrctiara ar on rite bark of thii•farm 23.Site diagram or additional well details:
You-may use tie back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction derails. You may also attach additional pages if necessary_
For multiple!refection or aunt-barer supply welts ONLY with the,sami.eonstradiosr}you can
satvnu one form. SUBMITTAL INSTUCTIONS
9.Total well depths below land surface. 24 (t,) 24a. Fur All Wells.. Submit this form within 30 days of completion of well
Fortnulrlpfr wells list all depths ifdlti'rrnt(example-3@200'and 2@ A'p' construction to the foltoning:
10.Static water level below top of casing 10 • (D,) Division of Water Resources,Information Processing Unit,
if water level Is above casing,ase••+" 1617 Mail Scrwiee Center,Raleigh,NC 27699-1617
II,Borchote diameter:8" _ (in.) 24b.Err rle( t(on WcU1.ONLY: In addition to sending the form to the address in
24a above.also submit a copy of this form within 30 days of completion of well
12.Well construction method: sonic construction to the following:
(i.c.auger..rotary,cable.direct push.etc.)
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a,Yield tiglim) Method of test: • 22•c.For Water Supply&Inlcctilin Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the coimty tealth department of the county where
13b.Disinfection types Amount: constructed.
II
Form GW-L Noah Carolina Department of Environment and Natural Resources-Division of WaterRmatrtes Revised August 2013 •