GW1--06576_Well Construction - GW1_20231006

WELL.CONSTRUCTION RECORD FortitcrnaluscONLY:.
This form can be used fir siicgle or mat wells
I.Weett.Coutractor•Information: ' •
-34AWATERZQNFS • • ! -
Brian Ewing FIWM TO 1 DESCRIPTION
Weil Cotittxctor Nome- ft; ft. 1
4240-B tL
NCWc11ContractorCcnifi�rtionNumllcr 'SS;:OUTERCASiNG'(fhfinuttr=!Wit iiclls)'ORL1NERofgp"(kabkl'
FROM 1 TO DIdMET6R• THICKNESS MATERIAL
SAEDACCO f4 fL' I is
•
usgd-toiil►
Company Nome. 'MANNER CASING'OR'TUBING(L'eai i rm_bt'ell,t^,.` -
FROM TO DIAMETER THICKNESS MATERIAL
2. Ycli ConstructiimPcrtuit4: o . It. 20. ft. 1 i "hl. SCH-40 Pvc
Liritillapplirpbk wilt primits(i-c.County.Stay.Vnriarme.h/ecfig or.)
R. ft ire.
3:Wdj[)so(cheer:wdl tisc)i • •47:SCREEN
'WaterSpppiv Weill ' FROM' TO I DIAMETER SLOT SIZE THICKNI S I MATnium.
. ' CIAgticultuta! °Municipal Public..
20 it. 30 ti• 1 . ra' .010 SCH-90 PVC
©Geothennal(Heating/CoolingSupply) ®Residential Water Supply'(single) • ti. /L, in, •
DlndustriallContntercitil ©Residential Watcr-Supply(shared) 1 GROUT' ._ " . . ;= _...., - - , ..... -
1rRoat. To. MATERIAL h EMPLACesfsvr METHOD,,kAs�towr
❑Irrigation• . . :ft. ft,
Nan-Water Supply Well: •
R. ft;
5BMonitt}ring fl1Zccovcly , ._ _,
Injection Welt: • _ ft. . R. .
CDAitttifcrRechiarg0 • ciOrourich,opt RCAiCdialioll tt42SAND1GILIYELPACKgif atryillimbfr•):' ,-, :'--' , - _-- .
"FROM TO MATERIAL - •.RAirr.ACLMENtMETHOD
❑Aepitfer.StonIgc and Resetyely OSalinit<'Ratrigt 18 . R.• 30 ft. FILTER SAND # 2 '
❑AquiI rTcst• ❑Ston'rts;llcclintinage fh. ft. ,
❑ExpetiniCnialTcchtutlogt' 1:15rth5ictcncC.C4nfml . - ,20:3RILL1INGLOG'fntiacb'additiooai'sheets,if:neeeSsnri?.. . • .
DGeatltenual.(Clased Loop) OTracer FROM TO DESCRIPTION(wtor.tianaaet,Rim nnk lnx ruin A.a dot
❑G'eothennal(ileatinei'Cooliaa Return) ❑011ter(explain under#2l Retnarks) 0 ' : .1t,, 5 ft, FILL, SILT'AND SAND
5 ft. 20 ' II. SILTY SAND
4.Date Wells)Campleled: 9-6-23 Welt ID#TH1^1-1 20 'ft. 30 • ft. SILTY SAND MOIST TO WET
54.Will Locatitln: ,fL ft, (:". r - ;
Tram Lumber. Company . ft.- ft, «k �" i.4-o e
Facility,�€hr•rxrName Facility WI(ii ppiicable),, R.� rt. — —
.O•C T 0 u 2023
485 Burney Rd., Asheboro; NC, 27205 ft. ft. "
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F s,eul Address.Ci ' and Zip _ to i:r -,1'-'1 ?'' .-_,..:J t!C;r
;21:tIEM1fAitICS -to-.
Randolph •
BENTONITE SEAL 16 TO 18' ' �D
• Cooly Parcel!astute gIou N .,(PIN)
. Sb:.I.ittititde and I.lingitnde in dcgrvcs/minutcslseconds or decimal degrees: .22:C motion:
(!fuel!held,one latrlocig is srrflleiod) ; .
• • •
N- • NY B.r�ina,n•.EwI r1 . 9/19/2023
' SigmturorcertificdRrcllCantractor •' .' Dale
6.is(are)thethewell(s)r al?ennauent or ElTemporar}' tlr,signing this fa nr..1 ircrrby cerly rruf ilk wellfs1 icuy(isrrnij c..dayinrcted irr;snandanir
Weir/Sal Neale 02C,Ohm or 1511 NC4c c.c;i20,9 Well(Winne/ion Srorafords anti Aunt a
7.Li.this a rejlairto an inistin$wan: t7Yes Or :t No reyrpoft1us rreont!tars-bren l;mrirkd'to.seal!anll tints.r,
If rhls:it o r►}kiir,fall cgir kothw!tall t tmttlict;o Grforoitulori aria e.p!aln rtu:.tutrire of the i .
repair nridrr021'rrvnarkssrcriun arrut the bizti of thiv fore. 23:Site diagra er.additional well details:
You may use the back of this page,10 provide additional well site details,or-Well
8:Nattier of Wells constructed: 1. • • ' cousttuction details. You May itlso•attacIt additional pages if necessary.
For tnnlrlplg titfecrinn or deernYIrer supply tesp arty ill rh rtiu.saure corrsrruiliat,inns curt •
sedmiltdate firm. SUBMITTALiNSTUCTIONS•
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9.Total Well depth below land sui11 ce: 3U (ft.)_ -24a. Par All Wells: Submit this,Fomt within 30 days of completion`of well
For nrirltiptc,iiTlis list all idprhs1fdlf rututeraeptc-5@2tl9'irrul:2@1OO) constnictionto the rationing: • •
10.Static Vvater level helots'top of casing:' 4) Dii•isiun of Water R soitrcc3,InformationPeaeessing Unit,
If bumf level is above raisin;,tar'•+" 1617 MailSer ice!Ccnter,Raleigh,NC 27699-16[7
11.Rarchote diameter 2.25" _ (in.) 24b.For Infection Well'ONLY:;in addition to sending.the font to the address in
24aaboi'e,also submit a.copv of this form within 30 days'of completion of well
12.Well construction method:DRIVEN consiniellon(011ie following:
tic.auger_rotary,cable,direct push etc.} j ,
Division of Water.Resaurces,Vnderground Itejectkon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mill Service'Center,Raleigh,NC 27699-636
Q3a,X(clil'(gjim) Method of test: 2�For Water Supply&injectroti Wens: •
Also submit one copy of this form within 30 days of complefion of
I311.Disinfection,type: Amount well constmction to the county hcaith department of the county where
constructed. ,
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Farm GW-1 Nonit Coral uui Depanmcnt of Hm irotuuctu and Natural Resources-Division of Wat r f[rxrnitt Revised August 2013