GW1--06644_Well Construction - GW1_20231006

WELL:CONSTRUCTION RLCORU I'.
Fqr lit;crttal tJsc;DNLY:.
• • This"forin con,bc used for.Stugl or tnndtiplc wells
1.Wc11.Cbntrterorinformation: • • .
U WATERZONES r • . . . . .
. Rich Lemire MIONr: ' TO. DESCRIPTION
WollCor*ugot,N?tnI4 ft: it, 1 I" .,
2593A • • It. f!
NC Wall Comiacror C ertiftcalioa Nuriter 1 OUTER CASING1far6lutti=eiiiiihsellsti'OR LINER filapptieabkl
- FRONT • TO - • DIAMETER' - "uncioarss- MATERIAL
• SAEDACCO - ft.. fI i, 3a •
Taut iaayNana .16 INNER'CASING'OR-.TU8ING:(pt5ithiii nittluS Hdiip4,'''-.-••
FROM . 'TO-. ' DIAMETER THiCKNESS' MATERIAL
r.wit i-coo strlietioa'Penuit4 o R. 20 -ft. 2 SCH-40 • PVC
LlsrirllnFphriibl,:trcllpeiwv (fie.Counts:•Stirrte,Variance,11an6 4 et„)'
-ft.. ft, - tn. -
a well li ctebccicvtelllasc),:. ;al:SCREEN .
Water-Supply Well: FROG]• TO DIAMETER' SLOTSi7a I11iCIXNF S , 1]ATiRrat, -
DtlgriC1111piai PJ141(iiiicipaliPitbhic. • 20 'it:• 30 `rt,. 2 I . .-010 SCH-40 PVC
IiGeotbemtal Wearing/Cooling Supply) " lJResiideiltial•Waler Supply(single) ' ' fi. . r� its, •
- . . CiluduSitialfComntemial ElResiden0a1 Watee.Supply(spared) ,'8.PROhT.G_ROi}T.:._ _ :: . _ , -- _
O h7i{.'nti0ll .. . . 'TO. "�1TATERIAL ENIPLAC'EiTEYT AIEtiIOD di AMOUNT
• - . . O. •ft. 18 .ft, BENTONITE CHEOBREb' '
Non Water Supply Well:
am.
Mprt lnnng PRecnyrtg .
In)ectloo Well: ft. . It.
DAqutferRcclvaigc. • LIGrot]nilWateiROnlCdiatioi 19:SAND;GRAVVEL'IACK•(ifupplii�ahte4 __ :. -.: -- -
- - ....mom TO MAtritr-AL. r ' EAIPLA--CEMENT\tt'Ttinn'
• CiAqurI r.Sloragc•atxlltccaiei• l7Salinitt Hatticr. 18. ft.• 30 R. SAND #2
❑ ignitcrTcst OSloruus iteri}riin7 c'
DExpsnmcnlal r 1moto •. 13Srtbsideooce.t_`onirtil
%:20 DRILL1l\G'LOG7attach addiliaieal sherts if ricccssii i•1
't]Geodternril(ClrisedLoop) OTraOr - FnW,rM• 10 ' DF.SfRiPT1O\tuotir.hsiontss.sianittitynt,4run Amato,
. DGeotltenital(ReatinyCaoliaeReturn) DOtlter(espluiuunder#21Remarks) 0 ,It.. 30 -ft. ORANGE SILTY SAND ' .
_ - ft: IL.
" -L Date Weil(s)Copiplefed: 977-2023 'Wit En.Ii GTA-5 '
rt: rt .
5e,WEll GIcathm: .fi., ft. y ° .�..e C.-.4 >�d I.. '
WIX FILTRATION . fb- r(: n ^��
3.
Facilityl4irricr7Jtuac Fact�il}'!I)><(iCappii able). R. ft
1301 E. Airline Ave., GASTONIA, NC, 28054 ' . ft, AL. II:.r.rn,r t::a ?!;-:, r.'� ',I , -
Pilrs duI.Addi,^sS.City ural zip ' a21sRLMARKS r+th`
•
GASTON •
(hmwy - Parce]Irkntirrcuilon No:(PIN} .
i1T:.I:ititirdc Intl I gir iiiril in dclttreg/tniitutrstxcond_s nr cict itn tl degrees
. (lf wcll'1"Nkl:gm;latlptsg ia-:sttflcckiiI) 32i�'crtitieatiun: 1,
• s •
V 9/16/2023Iv -
• • .5igmlun orcrtii WcllConuactor I, Dale •
•
. 6.Is(are)theavell(,)t 9P4.nnaneDt -ur xffemptoraty .
Hy 53gnhty del:faun,.1 hereby eerrdfv illru the'refs)tsar(nrdJ cirrstrircred ht:gq ordra'cr • ,
uuh'151 N,CAC 113C:orm.or 15.4 NC tC'02C ti200"Vol C oJ1stiliv tsar Standards end data a
• 7.Is this a reitartu i an cziiti:n;Weill!' DYed "Dr :No urimdit u cream ldrdslNen iirovirtrd rain.str.R ioii'u r,
If dhls lt•o drpxdlr fig Or krruttai i ill eimontellott bt)c,rrnatJon.rrirl L%pt.,*rise d drnre of the-
, riipair tauter#2,Ertsncr1d:seam or al then iJ.."of(f Porn - '23.Site.diagrarllilr,additional-s etlde'rdlils: • '
You may use iha back Of this page to`pmeide'adiitional well site,ifeLtils;or Well
8.1lntuber of wells eotislructed: 1 eousiructiou details. You May ilso;attaeli additional lieges if necessary.• ,
Fortimiddpte:JtiJcrilon ud•tarns-i firer tupplyieefls ONLY irJrh rhe.smaeionstr teifo r,);-on eon
.rafpnit e,ie form._" - SUBMITTAL iNSTUCTIONS .
9.Tt)tal Well depth beton land surfaces 30 ((Y,}_ 24a. Fur ALL Wells: Windt this foan within 30 days'of eoiuptetiotrof'welt
For irattdplcicetirlistnfldeprOsifdaft-mulexaalpte-e300'dot l.?0147.01 • con5lmetionto the toltotiinS: I. - -
10:Static%s titer.levy belutti tap of easime. 24. • 011.). Divis'san of Water Resortrecy,Information Plneessing Unit,,
if Hiner teed Li ihore editdg,itte'•t" -.18 t711Iait.Sci vice Center,Raleigh,NC 27699-1617 ••
it:I3orehote diamctet:8.-25" (in.) .24b.For tjidei Ilgp Wens ON X in addition to-seniliiig,Aie fomi to the address in
24aab66:also submit a-copy of this bait within 30 days'of,completion of tW11
12.WelEeonstructiou method:AUGER construction to•the follotvinwr' I• -
•
(i.e.auger iita ,_cable direct push.rte.} - • • • 1,-
- Dlv'iyioit of Water.Resources,Undergound Itf]eetlon Control.Ptngtaur,
FOR WATERSUPPLY WELLS ONLY -1636 Mall Semite center,Raleigh.NC 27659,-1636
13�7,'Y sld '•2.1e..For Water Supde fir Infection WclI •
'f►n1 Method oftcsG .Also submit one Copy of thus;foln Within 30 days ofcompletion.of•.
1311.Disinfcesiun,tylpe:_ Amount: -wctl coustmction.to the•county lic:Ith department of the,raisniv where-
,. '
constricted.
•
Rum GW-
Fo t . 'NonhCatolisa llcpan rent.of Euvirotuucfu NO'Natural Resources-Divi;ion of WatertRematr'ct , - -Revised August i013
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