GW1--03570_Well Construction - GW1_20230522

I .
WELL CONSTRUCTION RECORD �ll�� For tatcnralUscONLY: l
This forin can be awd roT single or Rurldirk wells
1.Weil.Contractor luforniation:
tJ:1YAT1 R ZON YS
Scott Hunt, Jr FROM TO DFSCRIPiIOK
%V01ConirtctorNamo 30 ft. 55 ft, sandy silt
4561-A IL fL
NC Well CalnracfarConirwotionNwrbcr 15.'OUTERCrISING ror Paul ll-casedn6hVOR LINER(if applicable
FROh1 TO I DIAMETER I THICKNESS I MATERTAL
SAEDACCO Inc 0 rh 45 fL 1 2" tn. I SCH-40 PVC
Cansp;ut)•NanW 16,INNER CASING OR" HING12goiberinal cluscd•loo i.
FRONT TO DINMETSR THICKNESS MATERUL
2.Wc1I Construction Permit#; WM0301278 R, II, m
fur<dtvjyrlicnbJr.urellpeneira fi,a.Cnrnrtv,.Srare,lirrinmr,lrferDCG etc.]
ft. ttr
3.WellI Use(ehcel:well D Sc): I7:S(,RLEN
R`aterSuppl�WcIL• FROM TO WAMET$R SIMT517Y. Tn1CKNT�SS sraTRwAI,
04ricuitutal ONfmlicipal/hritblic 45 It. 55 It. 2" in. .010 SCH-40 Pvc
®Geothermal(Heating[Coolin8 Supply} DResidential Water Supply(single) It. 2
®Industrial/Commcrcial ©Residentially'atcr Supply(shared) 1Ftgio,rRO� TO MATERIAL E\[PL\CEh1EVTh/EtIIOD&AhfOUNT
❑irri ation 0 ft. 41 tit, Portland Tremie
Nan-Water Supply Well:
ft. ft.1XIri/onitoling Mccovcry .
Injection Well: rt. rL
0Aquifcritcclrarge 0GroundR;ticrRcrucAnion t9:SANWG1iAVEUPACKOf r,uc.WtV..
FROM Tp pTATFIIUAI. RHNI.,L(:F�1r6:.\TMr:rllprl
❑A4uiferSroragc and Rccovct}' Elsalinity Harrier 43 R, 55 It, Filter Sand #2
❑AgnifcrTest ❑5lor matccDrtatnaoc
rs. re
❑l;xperinrcnial Technology ❑Sabsidcticc Cotartll
'20r DRiLLiNC'LOG(attach adr[itionaisdcets if•ncccssan•r
DGeothennal(Closed Loop) ❑Tracer FROM To DESCRIPTIO r•(mbr.fiardnen uffnrck IN x:rain W.)
Weviltennal(FleatingCooliug Return). 130dwr(Mlain under 921 Rettratt s) 1 ft. 3 ft, gravel
3. It. 30 (C red fill dirt
4.Date Well(s)Completed: 5-11-23 Well ID#MW-13
30 rt. 55 r4 sandy silt
Sa.Well Lrication: " £a
d-i L
Merchants Metals R, ft.
Fac1N1yX1vvocrName Fact3itylD,r(irapplinble) ^^ 2
R. fh
165 Fanjoy Rd. , Statesville, NC, 28625 R, ft.
Plryskd Address.City.and Zip
-2 I.REh1ARKS
Iredell Bentonite seal from 41-43'
Couulp No,(PIN)
Sb,lattftude and IAngitude in dcgiCe•S/minutcs/seconds or decimal degrees: 22.Certification:
(IN101 nerd,one 4w7oug h Srrllicical) /� "�
N W GG/7i{� 5/14/2023
Slglnttlrc ofccitificd Wcll Can tar Daic
6.Is(are)the well(s)t mPernranent or ❑Temporary Li)-signing rlrir farm,1 hereby cerfify dui Me u•dl(s l pus(Krm)convinreird br riedwr lance
with.15A NCAC 02C.0100 or I.Tel N01C 02C-,02011 lVelf Conamcdorr Srandards Braid An<r
7.hi tith a repair to an existing well: t Wcs or Mo. aorta ojrhir record bars been pmrided rn]lac urll(Amer.
1f rhfs'Is.a repair.till 4Nrr47,6n'A n'cll cnrutrurrlon brforrnorlat aril a plabi ire aware of the
repair orrder a2I remarkv neaten or cvr the back of efts fnrur. 23.Site diagram br additional well detakW
You tuay use Ilie back of diis page to proxide additional well site details or well
8.Nutuberof wells constructed: 1 construction details. You Ring also attach additional pages if necessary.
For ruarltlple IrUcrrl m or orvi-nwrer suppf:r wells ONLY i4rh rfu sane corrsh'ucrlorr,}on can
sabmironeform. SUBbTITTAL INSTCTCUO.NS
9.Total well depth below land surface: 55 (p,) 24a. For All Welly Suhnut 119s futni vvilhin 30 days of completion of well
FornruldpIr ivells list aDdeprbs lldlp'erenr(exaoro(a-3@200'wul2@100) construction to the foltowing-.
10.Static water level below top of casing: 30 (D,) Division of Water Rmti ivi!s,lnfnrmation Prucessin-,Unit,.
ijubrer level&above cudeig.am"+" 1617 Rlail Service tenter,Raleigh,NC 27659-I617
11.Borehole diameter:8.25" (in) 246.Ur Dl MIlita 3Vc119 ONLY, In addition to sending tikc:fomi to il►e address in.
24aabove,also submit a copy of this fann within 30 days of completion of well
12.Well construction method:HSA construction to the following:
&C.aagcr.-rotary,cable direct push•ctc:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636-Mail Service Center,Raleigh,NC 27699-1636
13.4 Vidd Wro) Method of test: 24e,For Water Supply&Injcctlon4clis:
Also submit one copy of this form within 30 days ofcomplelionof
13b.Disinfection type, Amount: wcll construction to the county health department of the eou",where
constricted.
Fonu GS11-1 Noah Carolina Deptrtritenr of EndrolWMnand.Naw al Rcsources-Divirlon of Water R i�IIC Revised.August-No 13