GW1--03564_Well Construction - GW1_20230522

4
WELL.CONS',rRUC rioN RECORD Fprt=nwUsct9NLY:
n,;s forincam lie uscd far.single at ua iiipk ivdis'.
1.Well 6utraeto(r tufortnaion:
':=1JAVXrEEL'L0NES
Stefan Smith FROM TO n6SCRn*1"10\ -
1`'ell Ctlt'Ard6i4r t`aflre R. R.
3576A fl. ft
NC I4c13 CamlactarCenification Nwrhel L5:0[ITER Cei5i11G`((bi aiufll caved'rscOs'OR LiNER'7tf.a i iilcablel,.:.
FRONT, TO ntasrfTER Trurt;VI IrATERat,
SAEDACCO Inc - 0 (t. 1 23 (L 1" In.. SCH-40 PVC
Can+pourti hanr4'. 46`,'INNER ASING 0R'TTI6LNG f•cl]ilrermdl etosvd4oa'1 =
FRONT I TO D_MIFTER THICT{NESS MATERUL,
2,Will Cunstrpt tion Pej Mjt R; WM0301280 ft, ft.
I.iteirRrry�lic�bler ctlp�nrtitsiir,.Gomrty$rr:r.,l$riararr,frjetbffflPSI=J' (1. 4. im
3,NNctl Mc(ehcck.r*dl tiscl; M SC II
Water Snppl�Welft FRONTTD DIA�ttt M StAMS173; •r111CKM3S SIATM A1,
riAgactdtuml CJ?rliitiicilztUTrublic 23 ft- 33 It. _ 1" in O10 SCH-90 PVC
®Ge 111cin a t(He ttingiCooling Stppty) ©Residential Stater Supply(single)
®IudtistrialfCoutntcrCial ©RcsidentialWiter,Supph•(shamd) 'Aff.;GROUT-. ;_.-
FROhr. TO. J(ATERL L I EMPL.ACE\LENT litru IOD A AMOMW
EJIrrigation ft. (L
Ilau-%Water Supply Fhclt:
MMunitnring Mep'cr? R. ft.Itiieri Da Welt:
rt
aAt111'Ifer ltcdiarge RCnicdi;i11611 19lSaEiVI11t;IL44E1 PhCt�Yif u r rllinbtcY''
'NRID51 TO MATERFAr. tiCFH1:NY'-;F:\1PI,, MLTntln -
i7A�ltifcr Stord$G at]d Rccot:�1�' C3$aFiilii}�8artict' -
❑Agit1fcrTest 0816n,mtatcr l}rtifl:Tl c
17E ]etinlcntllTcchnofngt ASlibsidc>xc.C4utrtil 1tloRtLLttiG,L(iG'(alttcliadiit�i�n'slshcels`lfncecssrirtl.
0G;odiem]ut(Closed Luop} l7Trdur FRONT TO pryettteTirvN twbr.l,:mine",sraa'nKr ty rxi ,i iw.ctr t
t7GcV4hetinalftalitk?XoditigReturn} O0ther(explainunder421Retuatl+s) 0 t4 14 rt silty clay
14 It. 27 TL Silt'
4.Dete JVell(s)Q;augdcred: 4/25/23 %VeII i11ftTMw=5 _
27 It. 33 (L sandy silt T^ 4
5a Hre01[ucation: L tt
Premier Tech (L. (( 2 d 7023--
FacilitylloivacrNam Facijht.lDM(ifappl cable) .
.
111 McNess Rd., Statesville, NC, '28677
Pikpiq AddreSs.City-afld alp 21a rt�hr�Lt(ti -
Iredell Temp well installed thi:u DPT rods.
county Parcel l[1_uiitiC rdou 1Jp;(PIN)
Sh..�:;ititndc and II,dngitudc in ilcgive'dminutudkeonds at-decinul- Cglres: 221 Culitirmtion:
(1trrlt mill,ura 1:unyug#s sldllcirrdl y
35.758011 80.79491 �v _ *r " 5/9/2023
SigcYified t4'cIl Caii[rdetar I)aic
6.I8{lCL'J LLe 1vell(s}: OPerni3ttent or ETempor>,i}'
tip.ephtg thh'ferret;.!lrrrgZ}'certife trJtl1 717x 11'CIl(5'l im.f Smv t! CYO 411#Cterl lv,ue•Carelan
1614 fart JVC. Ac 02C AIfk1 nY 1.m NCAt"QC' .02M)WWI Coit,07orrdar Swae(ards a»d xfwa a
7.Is tkk a Irepafit :tu an Eil-da'.wellt 0Yew Or, EN1t iriliro��thfr r,'[firyJ b is f`r,-❑�r?mided r?7ltr crt:ll rneripr.
(f rhts:k r rep-Myk.fill rnrr krronvi Iveff e-rraonwfiam trrf#rtAry) »arrad ct(afa!»dre iwave of die
repal"r rarl'rr 6V remark-s.v lhrri ar iai the brrk of rMy for»r. 23:Site diugratu'or additiouut%vell delliili:
tan may use(lie back of this pag.io:prol'idea':tdditiona1 well Site dCY:l*or tiell
8.Nutuberoflvells ioustrtleted: 1 consttuction details, You inav iiU- attach additional piges if Ikeessuiy.
For ntalrinle ird?.viloa or vfni-itwer sul!pfy raids ONLY whii rfiv.saive corrstrrrrlio+r,y'Crr nva
�a»rlr »�•fir,». SUBMITTAL INSTUC rMs
0.Total welt d4ch below land stirf ice: 33 00 24;L For All Well Submit this font within 30 days of comaptetion of well
Fornnrl]lykicells'ho tell derrfyffdfffr•rr»t construction tuthefolloning:
10.Statie itaW l6el belOn'till]of casinai ((y, Uh-Mun of Witter Rnaurievs,Inforailidun Piveinsing,Unit,
(f>tvee level h above closing,ilae"+" 1611 ALtil.Sa-vice Center,Rjlcir h,vC 2 7 699-16 17
i
11.Barchotc diametrt:2.25" (in.} 24b.Fr] WMIjou V 11 ONLY; In addition to'Seudingllle foml to the address in
24a kave.also submit a Copt' of this fonil within 10 days of.couipletion of i%Al
12..Well Construction Riethod:DPT constluedakh tn'the foff6wine:
(i.e.. gcr,ioian-,cable:direct push cto.)
Illvisiotl of�Yater l3csourcxs,Underground Injeetiou Control.Prograin,
FOR WATER SUPPLY WrELL.S ONLY: 1636 MA Service tenter,Raleigh,NC 27699-1636
13;t'Yield( fur) Me'diad of test: '2lc For Waters .Kr[n�cc#uen Wc[19:
rSLo subtli t on;e copy of this faith]ttlthin 30 da}'sofcoulpletionof
13h.Disinfeetion tapet Amnunt:. well cansinlcthlrb to the county heel alIth dcpannicta of the coiinh,where
eonmuctcd,
i
Fanu GIV-t eN'nnli Corallaa 17cp==1a.at•Eaviraamra arrd Natural R murccs-Division of%Va1cr Rr_-oLv= Revised August 1U13