GW1--04528_Well Construction - GW1_20230713

.i. WELL-CONSTRUCTION RECORD � Foy trramalUsc.ONLY:
' T]tis form egn.bc uscil fin single ar rnhltipk netts•
➢.�lCLI•CIIntI:IINC Information:
\\..A. . , ,
ta::\YAt tltZONES -
Stefan Smith rtt011 • TO beiCitt rlft\
Well Coritmctor Nam ft. ft. i . '
I .
3576A ft. ft,
NCWc19CmnmciorCcrtiftcalionNutrltcr CS:OUTER CASING'tfuriiiintartaseil-nclIsi'URLiN R'titan teable).. ..
FROM TO • DIAMETER 1REICKNF.SS MATERIAL.
SAEDACCO Inc 0 (1.. 5 tL 1" I ' in. SCH-40 PVC
Company-Name _16s1NNER.CASINGORTVBtNG'f.enthennaldusad-toiijr•<-" .,-. ..-
FROM TO . DIAMETER TirICKNESs MATERIAL
T.Well ConsU Action Pettit#; . R, rt. ia.
Lin'dicppilieybirv.•cifpeimits(Le.Coolty,:Stme..hitrionre,ii ecti err-,
rt. o. 6e.
3.Well Use(chccl:w•dl use): Al:SCREEN
Water Supply Well: - FIRMSi 1 TO brAM T):R sr.Or5nx; TIICKSrtis I u.►Tnnrnt.
C1tl8ricul[i1ral• D]GIulllcipallt'itbtic 5 IL 15 fL 1" ih. .010 SCH-40 I PVC PRE-P•CH
©Geotltem aI(HcatingiCooling Supply) DResidential Water Supply(single) ft. . fL .ih, I
0ludustrialrCotnotercial ©Residential Water Supply(shared) '--ttUGROUT _ -. .: , _. _..
FRQSi TO. ?,1ATERIAL 1 IWLACEIIENT METHOD MOUNT
❑Irrinatioti . . . . ft. ft,
NInt Water Supply liYetC: ft. ft.
6-Ott:mitoting' I]Rceurety
• injection Well: R. it.
CLAquifer Recharge . DGromidtlatcr Reiticdiatiaa .•r9 SAN2ICRAVEL,PACI ff uiyruuihte►:-=_•. .-.:- ^- - -
,FRi)M . .10 - A LATERrAL NSit't.ACi:\trir mErrrnit
DAgitifcrStorelge and Rccovety E3Salinfty Barrier R. ft.
•
DAgnifcrTcst ❑Stoinnn;ttee f}rainagc' '
ft.. (L
❑E perinicnial Teehnolot' USnhsidcncc Control
:2fl BRCLLi\G'1.0G(attach additional sheets if neeessan•) - •
-
OGeanthenna1 Closed Loop) OTF.tcer short TO DF,SCn.4PTIONlwbr.lrrntncay.taaVItn&Mx,vuuww.ctrtl
DGcodteunat(Heating+Cooling Return) DOther(explain under#2 t Retuatks) 0 . .IL. 15 'ft. Fill -
it. f.
O, ) 6-8-2023 TMW-1 riP.r ,-'C "'
�.Date Welts Completed: Well OD# rt. ft. j{f r-- 1 yy n`Ik --• t
5a.Well Location: • •4- ft.
Morrisette Paper . . it. It.' JUL 1 2023
Facility,'tlico:.i-Namc Facility!DR iifappliarbie) ft. ft, Pc.^^s Una
5922 Summit Ave., Browns Summit, NC, 27214. . ft. ft.
Phy skid Addivss.City_and Zip :lc.REhlhttt+S . -,
Guilford Temporary well; used '10' pre-pack screen
County Parcel kieiit ticullou No,(PIN)
Sb,Liritudc and Longitude in degrecaiminutcstscconds or decimal dcgrccs: 22.Ccrtitication-
(if tt ell Rend,ulri LOWS ig srdlie)cnu) •
36.174039 1., 79.717185 Wr _ 6/27/2023
Signnf c...t1ied Wcl Coati-actor
Daic 6.,E9(are)the 1veII(s): Llfi'ertnatient ar SITCtn&lorall By aigtung thin fey im,.1 herrh}•e•crt{fe•Ow thr wells)ma(isrn)cur-tingled iir;rt unhrnir
with 154 t1'Ci1C 02C,OI(19 or 1,t4•NC4IC(JdC.tr:00 Well Causer rtr.rr Srcumtards and sluts(t
7.Is this-a repair 0 art Oistinti welt: iVes Or ;IND ' 'teprofslur rrroniha..faun ill i ided 0)4,e cn-1i oitne•r,
1f t.'tr'cai 17 retNi)r.fill trait kiz(irvi u'tlf catu-nra(oti btPru-rtotr mil ee_tplahr the tatrare.if Me
rcaairaridrr P21 remcrtv:avian at-tui the back of this fornr. 23:Site diagram or additional w'eLl details:
You may use the back of this page to ptovicte additional well site details:or Well
8.Number of wells constructed: 1 constiuctiau details. You may also attach additional pales if necessary.
For tiralrl a mjeeriOn or owI-sour r supply wells ONLY with thr.Sirrrte M1Qrs(rw tlwt.yrtt cent
sihterirnnc faun. SUBMITTAL INSTIJCTIONS
9.Total welt depth below land surface: 15 (ft.) 21a. For All Wcllm Submit this fonn within 30 days'of completion of welt
For iirol(iplc ire*Hst rtfr dclvlts(fdlf,,i•runt to xeraip(e-3 213 T a10.2@ tilD) conSintr lion to the cottoning:
10.Static water level heluw top of easing: 6 (t.) t)ivisiuu.af Water Resources,Information Processing Unit.,
if unbar ward Is • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bhrchofc diamcter.2.25" . (in.) 244.For Ittlecttq 9 Weill ONLY; in addition to sending ttte form to the address in
2-#a`aL �•e.also submit a copy of this forte within 30 days of completion of%ell
- 12.Well consuuctioii method:DPT eousttuct1mt to•tlid following!•
(i.e.auger.snooty,cable_direct push.etc.!
Division of Water.Resourecs,Uudcrrauted Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: L636 MALA Ser Lice Center.Raleigh,NC 27699-1636
C3;i old(ggim} Method of test: '-lc.On:,«':itch Supply&Injection Welly:.
Also submit one copy of this faint4ithitt 30 days ofcoulpletiott.of
➢Jh.Disinfection ante: Amount: nvell constriction to the county health department of the county w•heie
contracted.
•Fanu GW-1 Noah Carolina tkpanmem of Envituamciu and Natural Resources-Division of Water€tinatrtti Revised.Aagust.20I3