GW1--03572_Well Construction - GW1_20230522

WELL.CONSTRUCTION RECORD For fmcriml Usc ONLY:
This rerin can be irwd fin.sin�le.ar rnullipk tssils
1.Well.Contractor Information:
"MAVATLR'f-ONES
Stefan Smith F14011 itt DCSCRIPTION
1`�calcaitttacrorl:5tac R. rt.
3576A
NCIVellCottttactorCcnificationNiniter 15.OUTER CA.SrNGIrn'rmul1ki%'rd%icHs1ORLINF.RAfai)ilicaBk" :-
MOM m DULNETFIt Tent t{� SS �TAITIMA1.
SAEDACCO Inc 0 ft. 23 (L 1'i in SCH-40 PVC
001op:utr Nautc. t64NNER CASING'OR=TUBING t'eni6errn d'eluuda>+i'
FROI ITO DNAIM.R I TMOLNESS MATERIAL
2:YYcll�anstr action Qer nrit ; WM0301280
Lift irrl cuynlicu6le xell peamitr(r:c.Coujiq,.State,Mariarce.11ysVd6q err.)
R. A. i>*
3.Wcll list(check well use).: 17:SCREL:N
Water Supply,Well: FROM [ To I nrASl.M.11 SLOTSixs Tttl(csrs uATRRraI.
CJ octlltuml 0mu]IicipaliNblie 23 ft, 33 ft. 1+, in. .010 SCH-40 PVC
Mkotltemral(HeatingfCooiing Supply) ®Residential WiterSupply(single) fi. rL m,
ClZudustriaUCourotercial ®Residential AYalerSuppi}(slcttedf AS.,GROUT:•
FROM. TO. ,l1ATERML EMPLACENENT.MEfi1011 C.010UNT
❑Irri riion h. ft.
Nan-hater Supply Wgi1:
P. Tt.. fill.MhlonitorinG pRLav'cp'
Wn cl[on well: —
GIAQirtfCt RcchargC C1Gcotttidt► tct Rctnediaiioa M SANING1 *1EL'PACKTir n
'IrRON To hI,L'rr;RWI. PIMPI.ACLAWNT%W"10n
❑Aguffcr.S(oragc anti Recovoy ❑ ilinfty Barrio R. R.
❑Aquifer Test 17Sloimn'1tcr l}rntragc
ft, fL
bExper{ncntal Tcelinotogy.. Qstthsidcncc Ca1Nro1
2O.DRELLING'I OG'faltnch'addiiio®itl'i -d. f accessary}
013hea wren!{Closer(Loop) OTracer FROM 110 DFWRIPTION(wbr.ttarjiioi,x+ta'nKk r'mctrt
❑Ca;otilenual Mealinv'Cooliug Return ❑0ther,(esplairt under 021 Retua") 0 t4 33 ft, silt with sand lens
ft. (L
(.Date Well(s).Cauipieied: '4/24/23 Wett1D#TMW-1
ft. ft.
id.Well Location: fL f4
Premier Tech ft. fL
Facility+ilnarNatuc Factual TIM(Kappli able) R ft MAl' s p
111 McNess Rd., Statesville, NC, 28677 ft fl.
FlrittA Addr:ass.City-and Zip �21:RENMRKS'
Iredell Temp well installed thru, DPT rods.
CaaW}• I�reC]ld•_ntit`ie;Uiuu Np,(PIN)
$11. l.ittitude aril Longttnile in 41M.Crsfminutolaccords 1.decimal dCgrccs: 2+,Certification:
(irt;cu raid.4trC i;tt1auy ig StcilicictU}
35.758011 i\ 80.79491 W f_ j 5/9/2023
Sieajtc'ii(iedPr'cllCaiitrd tar Date --
6.Is(are)the well(s): oPerinanent or ZTettporary IN,s{gnhtg thin farm,.!lrerebr cerrifn rhru file n•ell(si hvv 1»rnJ eonvirucrerP itr,Avvvrrhmc-e
ii*h 15A NCAC 02C.Ohffl or is t xctc me d)?00 Weil Cott mirrltai SkIman4s and roar a
7.Li this a repair to an c istim.welk OY+cv or ENO ecoyof this rrritirihrisInrn pmni;led vryj.M.%irRmn+ier.
1fr,Ws:ir n rzl-rlr,fillin+t kroUti Rehr,usnif lon lnfortrirrlen irnil. piahi the thmire of rile
re;rair tar lcr�'1.mnrtrks srxtian or ixn the biLd,of(Ah fora. 23.Site diagram or additimial,%vet(de'tr ibn
Y'bu may use ilie_back of this pa"g'e to.piovide additional well site details;or well
8.) umberof wells coustmeted: 1 construction details. You irtay:tlsu altacli additioual pages il'ua essaty.
For malrlple lrejeerhm or oOn-trurer s> tpl)•wells ONLY n•7rh thr-urior cairsrracriwi,you aw
su6mlrar,<jimi. SC111f1I[TTA�rNSMICTIONS
9.Total well depth below land stirfacm 33 00 24m For All Wells: Subndt lids faun within 30 days"of contpletiou of}.yell
For itralrlple ic'elh No tell deprbs tf4rf7eili hill) construction tonne foilorLinS:
10.Static water level below top of easing: (t1,) Diyisiun of Water Retiourees,Inf rmattlaa Prucess(ng Unit,
t}ruler le,trl Lis itbure easing am"+" 1617 hlait.Seiz•ice Center,Raleigh,i1C 27699-1617
11.B'archoic dimnetcr 2.25" (ta} 2ltr.Fnr fluttetlOn YVrlle ONLY In addition to sending Ilse feral to the address in
24-4 above.also submit a.copv of this ford] within 50'days-of completion of%Wll
11,Well COusirRCtion method:DPT Loustructioll to the follo%iing:
(Lc.aaga.rotor•,cable direct pasic etc.}
Division of ater Resources,Underground rajection Controt.Pr6grarn,
FOR WATER SGPPLY WELLS ONLY: 1636 ALtil Service Center,Raleigh,NC 27699.1636
13.4 lArcld(gt}m) N*tllu4l of test: 24c.FOR,Watck Site lily&lgicctiort-Wells,
Also subnut one fty of this fund Mthiu iO'daysofcotnpletiouof
vvcll construction to the county lic:ltb deparlm,nt of the county where
13h.Disinfcctiuu Q♦pe: Amount: � ,
conmiuctcd.
!
Farnt MV-1 Ronli Carolina Dcpaamcnr.of Environ incrn aW Natural Resources-Division of 1Vaicr RtLwwces Revised August 20I.