GW1--05967_Well Construction - GW1_20230912

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WELL COSIgtRUCTION RECORD Far hicrnal Uso.ONLT: •
This form can bc uscd Carsingle or multiple txclls
I.Well:Crintivetor.lifOrmadon: •- , . ._ ._ _. . .. ..•
14.WATER ZONES?':-.-2..=-•- -- . ',:-," , •
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Robert Miller .. -FROM'. "III)- - DESCIDI'llON
Wall CiitnclbtNAtir. In ft:.
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2675 R. FL . I I: .
NC Well Contractor CcitifitiohNMlbet ,15.'OUTER CASING(for iinuttl-catiril itellit OR LINER ill ari.litabk) .."- '- .• .
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FROM. I.TO -DIANIETER,' •• THICKNESS - •.MATERIAI..
SAEDACCO • 0 ft. I 23' •It, 4" i.,...1a.- SCR 40'• PVC
Compaay:NOthe. • • ' • 16.INNER CASING OR TUBING(geoillierrnal doscif-loop) .c '. ' ••"- ,' ,• .- •
• •FROM TO DIAMETER - THICKNESS - SLATERLAL
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2.Well COnStivitinn-Rerniit li: • . R." -ft.• -- ' '113.'
Litt a11.aFillistLible tei,11 peiiiiit 1(i.e.County.,State,l'oriarree.frefcrigteie.1: • .-_ . .
-ft.- • ill.
-.T.We11'11041(4k Wel ritiel:
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Water Supply tVell:.. FROM. .TO DIAMETER SLOT SIPS: TIIICKNESS 1 AIATERIAl.
.- . . .... 23' 11. 43' ..11. 4 " la,: .020 SCH 40 .I PVC
bAgitirlibral . Cildunkipaltruirlie'
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°Getithennal(Heatingidooling StipplY). OResidential iitaterSitiipiy-(single). Ii! I Jr.- ..ia.: .
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Olndustrial1Conimere'iiii °Residential'Water Sop*(shared) .inraUNt°UT::10', NIATEIH/O . I,ENIPLACESIENTME1110D&AMCIIINT,
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OletiOtion" .
. 0 'fr.• 19' ft. Port land pour
Non-Water-Supply Well:, , ., •
„.. ,- .. - B.-
• OiMoititoring. 0 Rccorcty
Injection'Well:: . 11:- 'ft: ',
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CIA.Mrikr Iteciiirgi ElGronridriotet R'.eritediation •19:SAN DI(RAVEL PACK fif applicabk) .-
.•FROM.-" 'M . - - 'MATERIAL-' . ESIPL10EMENT mrrtion.
, 0 ArtniferStortigeitiort Recottry•• °Salinily Ramer• 21' •fli. 43' .I1. Silical sand , 6/20 •
El Aquifer Test. CI Stomrivater Drainage
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ElExperintemal Teghoolog °Subsidence Control • . ._.. .
• • , . ., , .70.DRILLING WC touch additional abetti if nicessarvl '••, :-•.,,,' .' ''
bctothannalt,Clusedicop) °Tracer FROM .- TO DESCRIPTION fob r.hardorn.tolVnitk tvpr.-011iI)..4ir:dr.1.
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• 0Gtoilitnnal.(11talingt0 oliniRelunl).• litlettlier.(expliU tiOder.02 i Remarks) 0 ',D._ 20'- - I.r. Brown Siltlt ' '
20' •It. 43' (1., Rock
4.Date.S*01(S)Completed:-7-24-2023 NyeunkaDW-4 i
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fs ;VE F-
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SiiNVel!_11.;ocatititt:" ft. . 4:- . I. :
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SEP_ 1 2 2023
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Facility•OoDar Nam.. ' Facility 111#(i(applicall1c):
1420_Concord Parkway South., Concord, N.C., 28027 .0.: it;', ENtirOjeoci
Ik-..0C"il'1344!.4C51Yi 414 Zip' -21.REMARKS- •-• " , , ,
ea4bstini_4 .
2' bentonite seal from 19' to 21'
Calmly. Parcc1 Itinitificalion t413,(PIN) I
5Iii:.L•i0iiii 4 iiiit-1•01k ifijlic.ifidiliegF8i8m011ill4iir40iiiiii.!ii‘g'ril* ':•22.;Certification: I.
(ituall frald;ima t.ivicarg iS sidticiard) .
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.. N IV '"--- . . _..---,...-----;,.., 7/23/2.023 ,,..,..
. .. $1.gatur,of r.,-;::r.'i.e:o ‘r•t•-_,•:.rig•-s.wrc•"'"!---- - 'Dalc • '
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6:Is(art)the well(s):..13Pentiancrit or °Temporar) try signiiip,dri 1'form,:titirOu:erefifr Ihrii.Oic iiiafxri I.T.r(.re )t.:•OItytiliticifiiierf rikiner
.. .' tint 15.4 5siC4C.*,i)100..iir 15..t 11Cete:02C:02011 flail Consriteerkaf griimiar<ii<TII i tali*a.
7 Li:thiiR repair foiiiO4stitiinelli,. OVoC,- or 'AIN):. .c46....iif illis'recii.!ithrzi iii en j4r0,r414•41ro;14!*11 rrh:lier.
Ifs/ifs is a reAtieiiii isit krioilit writ embiri.rtion inforriiririon(Ira plitaliftlie Stilt ire of Vie .- '. • ' "" ' '-'• 'I-. .-'--1:.:....:- .'.. •
repair uridir 621 irmarkiSecaiimi or irn die briek of:etas-Arm :23.Site diagram or additional well details:
You niaf use-th'e..bOck`of this page tb prOvide miditiOnaill-site.detail's or Well
8.lininber of iv.ellicirrisinieteil: 1 .cOnsintetion details:YOU May also attach additional pagei:if neeessUis;.
toisttaildple if;10:1!ip`a-i oatfeater-.FIT&sills pm.r boor rhe 5.47Te-coji.!trireiion,you OM I:
AtSui.ii one film,: ' ,SUBMITTAL-INSTIIM3NS.:, i
9.1:Stal.Nilidelliii.belo*latiilStii(iiii:. 43'• • 0/011. 24a.-Itnr.All U'ellii-1.Submil'this librin within3ildays rif•abrupletiOri.tit littl
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' For mallipIe teellrlist.al 1 dept-WI f dgietenr1e.Tornple-.3@2AT cior126.1109.1 coristitictiorr to the folloning:-.' I: '"
10 Static nater.let•el Below top oteasing::21. _ 00 DiiiSiart Of NVit teiResoirieeii;Information Processing Unit
11 ilii1e t hi.')Ls iibOti iii-sirti.aie.-"+" 1617 Malt Screiee Criter;italcigInNC17699:1617.-:
11•,•Borahole dfilneter:8" :.(iii.) 24b.Fhr bileeilon-Weil4 ONLY: In addition to sending the form to the add re:ss in
244tlieve,..Utsu-submit-a Oopy'of 114 frimr.Within:40 daYSLCif'OftiOletiOir 91:4‘y11.".
12.Well conStnietion method:Air constriction Mille follotidiri:
(i:c.anger.roiar).cable clircd ittsli,:•cts:1
-- ' • ' - - " - .. ,DIVISIOn:0170tratei.litaittiriks,IJOdergemirril trijeetfori Control Pr,ograurh:
FOR WATER SUPPLY WELLS ONplre- 1636 Mail Sirs Raleigl4NC 276994636
24e.For WaterStripl .&Injettion'MclIs
13ii1cl'il02(irai ,.:l1iiiical of test:
A110:submit.ime,'eUtiy.-ufithiS f-emit ii-ithiri3(f.ria'YS of eritiMletioriof!:
Ljb.-Disinfectiou.-6ner. .Amoutiti. Wall construe'ion'to the cerrinty-heilth-.116painint;of Mg:county where.. . - - • CitillSiiiiClad,
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FOrto,GW-11 Nonb Caroltaa-Depaanteta of Ernlionniii and Naturafflesottrocs-pirftfontitfAialer Resca,...." Ittctscd'Airgi.iat 20 l2
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