GW1--06575_Well Construction - GW1_20231006

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WELL CONSTRUCTION RECORD Fur jraarnal Usc t)NLY:
Tglis form can bc;used(ur,singlcor multi*was
t 1.Well.Coutraetor Llformation: • •
• `I4::{YA1•ERZON1S. - i- . . •
Brian Ewing FROM. To OMSCItIP1ION
Weil Contractor Name R. ft, f '
4240-B R: ft'.
NCWd1Com>aciarCcrlitfcationNwrAter '�15;(IU7'ERCASING`(forinnlil=casedliclls)OR LINER'fifap Geyblc)
FROM .To DiAMETER - THICKNESS MATERIAL
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SAEDACCO tt, ft. I in.
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Comm.'Nam, '16IINNERCASING'OR;TIIBING:kepitieiin;tctu'seil.loaPp';' _.. .-
FROM TO- InAMETER. THICKNESS. MATERIAL
2:Well Constrvetiun Permit-*: 0 R. 20 ft. 1 Ilk. SCH-40 PVC
Lirirdll17,04,7m6l,:rr-rllprni i. fi_c.County.Strrar,Variarxr.ini4lien,elr) '
ft. . i O. � >ti
3:Well Ilse(checicwcb rise): :17:SCItEEN .
Water Supply Well: FROM TO n?AMETER SLOTStzr. TIIICKNMS I MATenrAL
. °Agricultural • DlidtinicipaljPublic. 20 ff: 30 •ff. 1 is 010 SCH-40 PVC
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17Geotltennal(IieatingfCoolingStipply)• IlResidr:utial-Water•Supply(single) fl, ft, in,
. MludustrialtComntercial ®Residential Water.Suppl'(slsared) -:1&GKO ..: - °;'... _
FROMUT .TQ. MATERIAL EMPLACEMEVT moron&AMOUNT
❑Irripsition . .. .„ ft. • .ft, .
. . Nou-Water Supply'Yell: •
6dMon(nrinG EIR over' f _ h.injeetlon Welt: -it. ft.
. t lAilllifer Rcc[iarge E:1070undwllct Reiliediation 19:SANDlGttA EL'PAC1CTif dp(dicttter` - - - = -- - -
• ,PROM TO MAMMAL FNFIACt\E�1 Htttol •
0Agnifcr.Stoiage and Iiceo:cgs. IDSalinily Battier•- 18.. ft. 30 ft. FILTER SAND # 2 '
. EI Aquifer Tesl- ❑ oin Slittaterl}rtinttge . .fa. tt.
❑EyrcrimcnlalTcrlmotot• OSrtbsidcncc.Conirul t• .20i DRILLING'LOG7altaeh "shcet`additional slf uccesssarvl .
OGeotltennal(Closed loop) • . []Tracer .FROM• TO ' D. cRIPTiONcooky.harduen.*IVoickOta.:r on ss e.dc 1
OGNUltennal(Eleatiny'Cooline Return) 0Otller(explain under#21 Remarks) 0 IL. 5 It, FILL SILT AND SAND
5. • • It. 20 ' ft. SILTY,SAND
. 4.Date Well(s)Conipleled: 9.6-23 Well IIWTMW-3 20 IL 30 iL SILTY SAND MOIST'TO WET
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54.Nell Liicativne .ft. -ft, , v 1 j
v ram-.`../L.rr V' Lam.,?,... '
Tram Lumber Company . .ft.- ft,
Facility,On•ocrNumc ' Facility I11k(if applicable). n =O--CZO23
ft. • --ft. •
485 Burney Rd., Asheboro, NC, 27205 ft. ft, 1n.�,.,r ., � r�r^,�-r,1;?S Ur q
PhykiealAddicss City..air4Zip =21 RtMAllKS" G`:.�J'��-wr
Randolph BENTONITE SEAL 16 TO 18'
County - Parcel hleidifcalion NO,(PIN}
Sli,-Iattititde and'Longitude in degrees/minutes/seconds ar dcdimal degt cs: ,21i C�aaaon:• •
(linen field;one lainotiy is•surriel.nl)i\ W- P;ri a n,..E`Aa i n 9/19/2023
SiP�it of Cenilied Well Cnnuactor Date
6.Is(!re)the Well(s): l7Fentiancnt or xlTempor iti7r Hy Aieiung.Ihiv finny;.1 herd)).cerly'Oar Mr well fr)rsvx f onte)Co,tnilyeted hr,mxor hike •
lark IP.NC,AC 02C.0100 or 15,1 NCAC(1W 0200 Well Cotrsrnreradur Sran darks and scar<r
7.is tins a repair to an iaistm,,iselli t7Yes .or Imo t 'ofrhis rrcorrl hrds limn limridrrd rn I(H:ii II muier,
Jf rhls.ft a'YOali:fill car knlmei well t o-rasrrircrion ltt pnnaliaft,rrid e.tplahi ritre.rtarare of the
reptnrtoiler t2l:rc,narts.srciiun or cm the bark of this foray. 23.Site or.additional,well davits:
Yon may.use ibe_back of this page to provide additional well site details:or Well
S.Natuberof hells constructed: 1 • . •construction details. You May also allachadditional pages if ne'cessaty.
• For i railWW pie.Jakeilon or rani-warer supply'redln ONLY Oh dm.smrre eoastriwtiou,_yrcrr,r n , •
sale irooe form. ' . SU1111iiTT,&L iNSTUCTIONS ' -
9.Totat Well depth hat&land surface: 30 ((t,) 21a..Fur All Wens: Submit this form within 30.days of eompteuon Of welt .
For anuhlpYrwrlir list iliarNotfdifarrroir(eratrptc-Se200*mm1.2,0109) consIui tiontoIkefpltol%ing; I
10.Static water-level below top of easing:: .' - (ly) - Division of Water Resourice i,Information Processing Unit,.
lfuaier lad is Aare cask;ear:"+'• 1617 Mail.Sdrsice"Center,Raleigh,NC 27699-1G17
IL Bore ude diameter:2.25" (in.) 14b.For infection Welly ONLY: 1 in addition to sending.the form to the address in
24aaab&ee,also subti►it a copy'of this fottii within 30•dais'of completion of well
12.Well construction method: DRIVEN construction Cadre followings:
. (i.e.auger ioiary,cable,direct push e(c:} .
• •Division of Water Reseurtxs,jUndergrouod fujecllon Control Program,
. FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Ser'vicetCenter,Raleigh,NC 276994636
13a Yidd(glim) Method of test: 24c.For Water Supply.&Infection.Welly:
Also submit one Copy of this funu within'30.daysofconipletion.of
13b.Uisinfcctiun type: Amount: %veil coii5tniction to the county'health department of the coirnh*whore
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Fenn Gi,V-1 North Carolina Depanme n of Environment and Natural Resources-Dlvisloaof 1lratcr Reotram Rceiscd.August 1013
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