GW1--03538_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD
For Noma'Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Tmfornlation:
:14,AV YrER:ZONES- .
Scott Hunt, Jr FROM TO ' DESCRIPTION
• Weil Con(r ctorNanic R. ft. i '
4561-A It. ft.
NC Well ConmciorCeniftcationNwrimcr 1S:OUTER CASING(rot^eunlikisedveeli OR-LINER(If s ne-abk)'.
FROM TO P Ad1ETER THICKNESS MATERIAL
SAEDACCO 0 ft. 4 IL 4" M. SCH-40 PVC
Company Nana; IF:INNER CASING OR:TUBING14cihermal clnsedarrwp).,
FROM TO DIAMETER' , THICKNESS MATERIAL
2.Well Constr ottion Permit#: R. ft, hi.
Lrtr all applicable well permits(i.e.Corrnry.Seam,Variance.Ljeetiuy etc..) ,
ft. ft. in. .
3.Well Use(cited:well use): 17:SCREEN:
Water Supply Well: • FROM TO D1AMF.TRn Sr.orsl71: TRICKN 6 I MATERIAL.
El Agricultural t�IalunicipalfPuUliC 4 ft. 24 R. 4" in. .020 SCH 40 PVC
rmal(Heat@ Coolie Supply) ®Residential Water SupplyfL fL lea
❑Geothe
� 8 OPP (single)
0Industrial(Contntercial ®Residential Water Supply(shared) -l-taiocRotrr To ' MATERIAL EMPLACEMENT METHOD&AMOUNT I
❑kriipntion 0 ft. 3 ft. Portland Poured
Non-Water Supply Well:
DMonitnring . I&RccoVely R. ft
Injection Welt: ft. fa
0 Aquifer Rccliarge DGroundwatcrRemcdiarion -'19[SAND)GRAVEL PACK(if atrplliable)':: .
-FROM TO MATninAt. Fano.Ar:r:11EVTmin-non
❑Aquifer Storage and Recovery GDSalinity Barrier 3.5 ft. 24 ft.' Filter Sand #3
❑AquifcrTest DSlormwatcrPritiettoe R. R.
❑Experimcntal Teehnotogy ASEtbsidcnec Cotltiul
• '20:-DRILLING'LOG(attach`additions!ihcete if teccssan l
DGeodiennal(Closed Loop) ❑Tracer .FROM To DESCRIPTION nob r.hummer,sottlnrck Opt.min Sief.Ha1
❑Geothermal(Heating(Cuoling Return). . ❑Other(explain under el Retuatls) o ft. 10 ft. cobble layer
10 ft. 24 ft. silty sand
4.Date Weil(s)Completed: 5-2-23 Well IDPw-zo ft. fL ` '� .Cwr L.i !d�;----
$a,Well Location: ft- ft. M/�Y €) (}Crown Food Mart ft, ft, 1u202
FacfityArlu•ncrNamc Faclllity 1Dk(if applicable)
ft. ft. Inri�il;':;.^n ar y=;,jr,,711n'4
300 Rodney Orr Bypass , Robbinsville, ,NC, 28771 R ft,- - Like.i.l,,b-4-L=
'Plrysicnl,Address,City.and Zip r•21:REMARKS •
Graham Bentonite seal from 3-3.5,
County Parcel(demif aUon No,(PIN)
Sb,Latitude and Longitude in dcgtxcslminutcs/seconds or decimal dcgr oes: 22.Certification:
(ifnen Gild,One hmluugIs$1101 4,a) t}-
N W 5C�w FV • 5/7/2023
S.ignutcira of Certified Well Con , tor Dale
6.Is(are)llle{{'CII(s): ZlPerTnanent or °Temporaty By signing tirLr fate,I hereby certify Bug the well(s)rsr(Kerr_)cunetnrcted ae mceortheice
with 15A NVCAC 02C.010R1 or IM NCrtC 02C.0200 Rill Construction Standards and that a
7.Is this a repair to an eristingwell: 17Y0( or ElNo copy ofthis Ore orlibesla'rn pnnidcd ratl+e urll eater.
If this is a repair,fill rut laroiwi well construcrlon information and tit-plain the rarrnre of the
repair under021 remarks arctlan or en the bran•of this foray 23.Site diagram or additional well details:
You may use the back of-this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple lifecrlon ornate-eiarer supply wells ONLY.w•lrh rhe.same carrsfritetian,you can
selfunitone form. SUBMITTAL INSTETCTIONS
9.Total well depth below land surface: 24 (R,) 24a. Far All Wells: Submit this form within 30 days of completion of well
For maniple iple ivell:list all depths ifdiftcreme(cxaarpi'e-J€2(t0T and 24)l00) constnicdon In the following:
10.Static water level below top of casing: 10 M.) Divlslun of Water Resources,Information Processing Unit,
if linter kiwi is above erasing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-I617
•
IL Borehole diameter 8" . (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
2-a above.also submit a copy of this fonts within 30 days of completion of well
12.Well construction method: Sonic construction to the following:
(Lc.auger..rolary,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
13a Yield{gym) - 4Yctlmod of test: 24c.For Water Supply&Injection Welts:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection ty-per Amount: well construction to the county health dcpanment of the county where
constructed.
Form GW-1 Korth Carolina t epanaie a of Enciroruocm and Natural Resources-Divfslon of Water Rerouon• Revised August 2013