GW1--03562_Well Construction - GW1_20230522

YELL CONSTRucrtON RECORD
. For[rtcrnal Usc ONLY:
'Ibis faun can be used An single Or multiple netts
1.W&L.Coutractoc Infornrailon:
'14.,A ATURZONES
Stefan Smith MOM to bESCRIR17t1\
WC11 ColArdClOr Name
i
3576A
NC NVeli Cei9mciorCcnifl©tionNuir,ber tS::OUTER CASING(r er'Oikikd"nc[1,0 OR LiNI fif i i`ticabkl. ..
FROM 'M 11F'rtut Trllm-4ES's rATERTAL
SAEDACCO Inc 0 - (t. 8 (L 1 1" In SCH-40 PVC
Cm,gl;w±N5P4, Iti ILNNER CASING OR TUBING`( �ihermal e6nstd lou" '
FROM TO DIAMETER TIIICIiNF.SS MATERUL
?.Well CorisUuction['er'rult 4. WM0301280
LUrrrl117,L irahlr.,sellpc-nmi ri:r,.C•oi q,.,9oje-l$rfaerrr,HJAbG3 Pdr J
3.Well list(cleglc Wdl tisc),i -17: -CRIMI
WaterSuplikyWell: FROM To nrasn! M SLOTslzs. I THICHnr-s 1 MATParal,
DAgricultutal D.rItinicip:lipublic 8 ft, 18 ft, 1" irk, .010 SCH-40 PVC.
®Gcotherrnal(1Teating-rCooli(>5'Supply) DRes'ideh(ial Seater Supply(single) ft, rL in,
©[tidusiniaUComotercial ©Residential WaterSuppy(slrtted) ;'t8iCROIffi•
FROM 1( MATERIAL I EMPI.AM-tENT ML-niOD&.IMOU\T
DBtri Ilan h. h.
Nqu-Waier Supply Well:
MMonimrirk pRcca�rr}'
lujecilort Welt: ft. FL
DAgttifcrRcchame (�IdroutdaaicrRcnicdiatioll ,19,'SAND;GlLiLVELPACre'(tr ,iucAtile) —__-
PROM TO NIATF.NrAI, ksIVI.ACLVENi MM1011
[7Aquifcr.St6rt9c anti Rccov6xy DSnlinfty 6artici` R. R,
ClAgnitcrTcst. ❑SloftnwjtcrIhain gc
ft.. fe
l7R rcriblcn(nl TcclmoIc"T ASubsidcricc Caigrot
�Ztl:t)R1LLi\G�IAG7allach�addHidnitl shceis'if iccec�swn'l
DG:tithemnd(Closed Loop) DTracer FROM I -to br�UR1PTION[Corer.harUacn,w4',+,cl�x.^rr n ssr ti de l
❑CGeothetatal(Heating.Cooling Return) DOlher.(explriin udder 421 Remarks) 1 0 (L 14 ft. Silty clay
14 ft, 18 (L Silt
4.Da[rr Well(s)Compkied: 4/24/23 �Veg lD#TMW-3 ,
51.Nrcil L/LCatilltl: (l. (L
4..
Premier Tech ft. fl. MAY 2 2 2023
FactlityXhr'ncrNamc Facitit)•ION 66pplicablc) R. ft. �l 4
Urn'
111 McNess Rd., Statesville, NC, 28677 rt rl in; ;;; ;a::::
1,1L� .
Flpkul Addrsss_Cill'_aW Zip z I aEnt.tft[:s
Iredell Temp well installed thru DPT rods.
Cpanly Nrccl Id:lldirrcationNo.(PIN)
56,l.iltitudc and 1.011gitude in ltcgt itninutcsrscconds or decimal degrees; 22.Certification:
lflu ell 110W,ow.lai.7yurj iy srrllrCi`ru} '
35.758011 80.79491 __ _ 5/9/2023
SiQnit�cYfficdlVellCad[4ctar, .._ms--- a Daic -- - -
6.I9(ure)the{YeU(s): DPennattent or, ZTetltporary By rgain!•lhir Jofm,.f herrLr eerfrJr(liar 7hg nelliaJ t}vx(xireJ rorsrrucred hr rcrorrhmcx
Wi lh 15,6low 0 C.01M or 1,rA NCAC 02C.tl'.f}9 Well Coastrrrden Srar,rlards ernef flurr a
7,la this a ertliaic to an Edxtialtl fell! CIVcr- (ir EM) is y,po3 fhir rerriiYl lrits'bcrn�rz,rirl d rnr7r.ar*1l rne,iPr,
If Misl,tr rslkrlr,fill c�,r k,ro,r'vL well reflwrlrctlnh hlforea Trion imd 67,1ah1 rile nae,re of rile
ripafr ender#21 remarkr.ser,ian ar rxa the Nick olrfei+jenrr 23.Site dint-Am or additiouat well tletaiLi:
Yew may.use the back of this page to provide additional%yell site details,or%fell
8.Ntnttbec of we%LouNtrueted: 1 construction details, You nap itiso attach sdtlitiotal pages if Ikt ossnn.
For mahlple hejeefloa e+r r,rui-vuer s„pj J)bells ONLY wkfi the saute c{„rsrrucliwr,pm eku,
submit SURNTI EAL lNST'UCTiONS
9.Total nelI depth Mow land surface. 18 (fL} 2U Far Atl Wcllw Subtuil this funs within 30 days'of completion of well
Fornfalflpfeleells list aflderrhs construrtionto the foltoningr:
10.Static water level belaw tap of casing: (ft.) Divisiun of Water Respneees,Information Prutiessing Unit,
1f umee level is chore r'asfrlg;rue"+" 1617 LAI Service grater,Raleihlt,NC 27699-1617
11.tlorchule diatneter.2.25" (in) 4b,r�ir tutecfian`Vella ONLY: in addition to sending Ili fonu to the address in
244aboye. also subtuit a copy of this fonu within 30 days of completion of%v&
12.AYell coustivctiou method:DPT construction LO the followings
O.C.all'cc fated',cable,direct rude eto.} -
Division of 1Yater Resourl�s,Oudetgrowrd I.jeetlou CouttA.Pr'ogram,
FOR WATER SUPPLY«'ELLS ONLY- 1636 hLdl Service(Center.Raleigh,NC 2 7699-1636
f3;e,Y[cld(�tm) \fiitllod of tCst:
24A For Water Sum]-( &[nICethllll Wctfvt.
Also subjiiit one c6py of this farm uithiu 3p.daysofconlpletiouof
13b.DisinfLetlon type: Amount: %"CII construction to the county health dcparonent of the connm where
eonstmctcd.
i
Farm GW-L Noah Carolina D:parunew of Eot'iromnem and Natural Reswurces-Division of Water R--oLrte= Revised ALgtrA-V0