GW1--03571_Well Construction - GW1_20230522

WELL.CONS'C12ucrION RECORD FarlrtcrnalttsoONLY: i
' This fonnean be used far.siogloor tualtipk n'clls`
1.NVcll.Cuntraktur Information:
-
--1-1.'A XM'RZONFS .
Stefan Smith FROM 10 nc1CRtpTt0141
t�'cll Colrtac(oriv7nu: ft. ft, l
3576A
NC WellCoviniclorCcniftcationNumber 'aS:OUTER CASING(fi"r'oioltk40dlicps OR LINERf11.aiSlica6k
r•noat TO nr'%%1vTER TmCl;y>ss sLt>Entat.
SAEDACCO Inc 0 f4 14 (L -1" la SCH-40 PVC
i:antp:ml[tau . 16ANNER.CASINGORTt39ING tntihciinrdrlused4on
FROM I TO DL1\tFTER T[rtCLiV6SS %IATERLALL
2,Weti Construction Pcimilt#: WM0301280 R. ft. d�
List#11 a Brasil rlrpehr in 0.r.County.Slw.c-Voriaiwe,frftacR e1 J ft
3.NVCH lisp(chccl wrdl usc): t7:sCI1FlN
WaterSuppty Well. - FROM F To InAMM FR st.orsM 'r11iCKNh5 I MArnnr,tl,
MgAcultutal cAllinicipaUl'ttblic. 14 ft. 24 R. i' itu 010 SCH-40 PVC
136 otheirrial ffleadniliCooii Qg Supply) Mikesideittial SYater Supply(single) (t• fL i'�
®3ttdttstriaUContnacrcial ©Residential l4'ater.Supply(slated) `t8z GROUT:.
FROM M NIATERUL EMPLACE.MM MM109 S.0IOQ\T
01nipation ft. ft.
Nan-Water Supply Well: ft. ft,
5010anitoring pRccovetq
Injection Welt: It. ft.
' 1vs,u�D;GI1 tut L'rAex rlr u t tuulbtel:" --_- -
0AiluifcrRc4 bar
gc 1763aoutidsnlcrR.entcdiatiou
FKos1 10 M.M1.RraL nsiPtACEtrr:,NTM.Pntau
[7�lgnifcr.Storuge and Rccovrr�' ❑Salinity'l3arricr
❑AgnifcrTest ❑5tontin;atcrl]rai.uago fL (L
❑Experimental Tcchno(ogy 13suh0derice condi-ol.
20:'URiLLING'I,OG t'attueh idt[106o'td 3tICCt3;f IMCCSSrIR't
OGeofltemml(ClusedLoup) FROM I TO Pri5CRiPTIO\(cobr.hnWnc.n,vjillt,Kk4N '"'ow
❑Geothetneat(13eatinuCuoling Mum) Ot]flier(explain under.42 I Retua ks) 0 tL 14 fi, silty clay
14 It. 24 fL Silt
4.Date Well(s)Contpletcil: 4/25/23 Well iD#TMW-6
ft.So,Will blugnin
R. ft.
Premier Tech ft. ft. MAY 2 2023
factlity,pnocrNutur Facl]Hy 169(i.fa•ppli ablc) R. ft,
111 McNess Rd., Statesville, NC, 28677 R ft,
r afi. a
F'ltisicul iiaaivsK c;ty'.anti tip ;:21;HE6iARItiS' - -
Iredell Temp well installed thru DPT rods.
Calmly ParrC]kknitife;idUn Np.(NN)
56,Latitude end Longituilc in dcgive'41m.inufalscconals or-decimal ctcgr'ccs: 21,C'crtification:
(If c�ell l'�CId,Rrn'.I;tl,70ug{�g¢lficicrd} .
35.758011 N 80.79491 W
- y�J e 5/9/2023 _y
Signale`rlficd Well Carivactar Dak-- -
6.is(are)lhe'w•ell(a)t oPennanent or XiTeuiporary J�•S401 rrg AEr fanm.l ffer.dn'rerfifr di,Iar Mr.irrQ(s)trrtr(erra)cVea_rtnre•red ru ereon(rmcr
ti•irh'15a6'C,tc 02C xm?n I A NC,tc 012C d12M)11 i•ll cousimakut SRtru(aids erruf ibrtr<t
7.L.this a repair to an c i3tiny;ixcll: E3 k t`w or ®No tYVy'!5 Oh ierkd bt7S bCrn prnt'ukd 6'Ow cut fl ai v er,
if IMi 11 o relMk,f)l t.,rr kr,own Well renirrtialr.ri b;furrrrrrtlosr rrul cxplrabi rbe mirure of Me
rrpTirrau1rr021 rvnar-..6rcaraa or im Me ba&ofMir fcrnr. 23:Site diugrtlui or additional,well detaits:
You play,use the bacb of this pEige to.provide addidiona[well site details:or tech
8.Nuttiherof li•ells constructed: i cousiluctiml details: You umv itiso attach addiliona!pages if necessary_
For nniklple lrrJcrMm oreowi-roarer suirlr)y inrfls ONLY n901 MI.s,nrreeorrstrtrrtiou,)an c uq
sol.n,lranc fi'mi. - SU NILITAL iNSTUCTION3
9.Total Well depth beloiF land slirfici. 24 (ff.) 24A. For All %V Ibti Submit this fonu within 30 days of completion of well
For miNple icelf0isr atl dewhi irdlf°rrent construction to the following:
NJ.Static water level licipw tap of easing- ((y,) Division of Rater Re-source
nfo s,Ir matian F!rumssiiig Unit,
if n'fxleF let-el!r irbove rasing,itm"+" 161 7 uu.Scr vice Center,Raleigh,NC ti 7659-16 L7
III,Barchcttc diamctca:2.25" (tn) 24b:!or Itiilrlia n 1, &t ONLY: 'in addition to sending.1he form to the address in
24dabow. also submit a copy of;this forin it•ithin 30'days'of completimi of wtill
12.Well consttuction method: DPT constriction to the followine�
{i.c.3ugci,taaar;•,cable_direst push.c[c.) l I.
DlviAritt of Water ResourtesJUnderground Injection Control.Program,
FOR WATER SUPPLY WELLS ONLY 1636]Hail Service CEuicq Raleigh,NC 2 7699-1636
I
1341,Yield(alien) Nlcthoil of test: 24r_For Water suyyly.&tw&tiort Welts:
Also subunit on:e copy of this fonu ivithin :all ftsofcompletionof
13b.Uisiufictiun type: amount:- _ w'cll conntmction.to the county bcW' th department of the coimh'wherewhereconstRictcd.
Fann G%Nr-1 n<otrtm Remised August Y013