GW1--03544_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This Fenn can be usca Cm single or multiple wills
1.NFiILCiintractor Leforniation:
t.I.AVATER+ZONES
Stefan Smith FRON1. TO 1 13MCRIPT1ON
1Vell Col-Artclot Maroc 11 ft. 15 ft, sand I I
3576A f4 ft:
NC.NVcll Cant>aclorCcnif=tion Nuirlicr MOUTER CAS i G(forriiult[cased uehsl'OR LiNERAf it''CrcW6,
FROM 10 MAIMP,TER Tfl MNF,,S I ISTATEnrAL
SAEDACCO Inc 0 P. 5 fL 2" in. SCE-40 PVC
Contlrun Naulc. A INNER.CASING OR;TLt81NGy eulturmaF eluscJ4rHip !- _
FRONT VTOI DUMETER TtQC{NESS I NIATERGL
?:YYc1E Cotistr uctitiu I'cr ttrit R. ft. nL
List trll rlpilira&!e tcc�!prtmits ti:r..C'ounnt Srtrtc,t i�rlotrer.Ir•Jecb'cn.-dr..J
fL. ft. in.
3:YVcll Un(e4cc1cwell use): ME EN
Wtiter Supply Well - - _ FROM i to DIAMMR SLOTSIM Ttncxxr_rs I uAraRrar,
13Agricultutal Cil4liinicipctUTuIblic 5 ft, 15 ft; 2" in, .010 SCH-40 PVC
Mcotltetmat(IieatinglCooling Supply) ®Residential WitcrSupplg(single) R, fa' in•
©lttdustfiallConuitelcial ®Residential Water;Suppb'(shared) 18 GROUT"
.
FRONT TO. MATERIAL EMPLACEMENT\fEI110D&A,UOU i'T
0Irrigation 0 fL 3 (4 Portland Pour
Nnti\Prater Supply Welt: ft. f1
phfpnitoring cry
faJeelion well: -
QAgitifcrRccharga MeimuMnuict Rclilctllation '49 SANDIGIULVE •PACK'lif'u l iIl6bh!), -
-FRONT To I nrn•rt;RiAt. r•:SMACIAD:Nr ttet•tlnu
❑Aitttifcr_Storrgc and RCcoN)}ry QSalin[n-Barrier 4 R, 15 ft. Sand #2
❑AquilcrTest, LlSdoinnrttcrlimin;�go (L. tt.
0Exp.-dracntalTMntutovey ❑SAtbsidcswcConlrol
4(l10RILLINGILOG tt hkh additior6I shear if ag&.san•)
C7Geo'dterutxl(Closed Loup) ❑Tracer FRONT TO I)MCR[PT70\knior,hardnc r udty+tcu Av Ki "n err,de l
17Cr otlieunal(Reatin Cuoline Return) Ot]llier(explaliu under 921 Rctuad%s) 0 fL 15 fL fine-medium sand
fL (L.
4.'DateWe11(§)Completed: 5/i/2023 Well.iD#Mt'17R2
dL fL
its;Well i.ocatinu. .fL fL
Lassonde Pappas Company f4 ft MAX
FacIlit},OnocrNantc Facility IDkGfappiiablc).
485 Brookside Camp Rd.,.Hendersonville, NC, 2.8792.
te, R.
Plltsical rlddtess Cih.and Zip ;21 REh1AttICS''
Henderson 1 foot bentonite seal from 3 to-4 feet.
CQOttd}• Parcel ldaatillb dMou Na.(111N)
Sh..i:iAtitudc ilnd I ongitiule in dot ces/miitutrs/scctinds nr dccini tl ctcgri"'. 27_Certification-
(if cell tx 1d,girt Iavlk)4 is saftickrd)
35.378088 1` 82.489455 �V _ _'*_ _ 5/9/2023
SigrntrcYificd iti'cIl Cantrxtar --- - ---- Date
6.Is(are)the itirell(s): XPennanent or ElTemporary 11M•s snhr Atr joim.3 hereby eerrifr r�tr r the a•eflfsl i&uy(45rre)cWr_rrrucre4 fa.r.•crorrfrtice
riirh 73.•t NChC Oe'C,111(k7 or l.rA NCrtC A2G,020fi n'rtl Lbrtstrrn�NNr Srann4rrtis ernd rlxrr tr
7.1s tliN at reiiair fu ati rmisting At'e11: L-Acs' or ®Nt► ier6alNh:bran pr»rirlrtl roars aril metier,
if rhis h a n;xrlr,fiIt rntr Awvnvi tv,fl crnwl)( fern hrfgrr11ule11 tmrl a up(ght the writra of rfie
rep,arrimler N?I'aymarkr wan m or ivt ilia!bcwh of this form. 21 Site diagram or.additi0uAl Well dehiil.Y:
You may use&.back of thus page I&Vovide additional well site detailsor*41
S.Numberof wells constructed: 1 construction ilelails..You roar•aLo a0ach additional pages if necessary.
For mttlriple irdeellim to rm'I-Ifurer s P#y lvr•f s ONLY 11101 rlie.sreme corrstcurriar,}�tt tutu
xat atn one famt. SUBMITTAL iNSTUCTiONS
9.'Total�iveltdepth below land surface; 15 (ft.) 2U For All Submit dds,fonu within 3L1 daps of completion of well
Foritraftipfe irells:list tell dep&-ifdiffi•rvn;(e.Freeriltf(,-3@21W znkl.243 UND} construction to ft fo[toning.
M.Static water level below lap of cminyr li (f.) llh-siun of Water Resources,lnfrir mAtion 1?rucessing.Unit,
I/nuier levrf 1v dhove cirstga iue"+" 1611 hlait.Sci•)•icc Center,Raleigh,NC 27699-1617
11.Borehole diameter.8.25" (in.) tab:For hilallail v.lie ONLY. in addition to seodmi g tl►e form to ilie address in
24a abbot~also submit a copy of this fortis within 30 days'of completiau of(tell
12.Well construction method:HSA construction to the followine.
(i.e.auger,rotar}•,cable,direct push.eic.)
Division of Water Resources,Underground Injection Control.Prograin,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13;n Yield(��rm) �'lcttroif of test: 24c..For Water Supift&[njcctlou:,.Yells:
Also subunit ore'eopy of this foam withitt 30.daysofconlpletiou017
13h.Uisiufcetiun tree: Amount: wctl conoruction to the conniv health department of t[te county where
constroctcd.
Fomi G%V-t North Carolina flcpanmem.of Eadromtmuu and Natmrl Resources-Diviiion of Waler Rr aireES Revised Augt6220II