GW1--07217_Well Construction - GW1_20231108

i
- WALL CONSTRUCTION RECORD Par[mend uscONLY:
This fohn can he used to single cr tnultiplc wells
1.Well Contractor Information: '
ta::WYATER:ZON)S• . . -. ( i.
Stefan Smith FIW51 Ti) Dt RI'I1ON
Well Contractor Name fi. ft.
3576A ft. ft.
NC Well Contractor Certification Number 1• •OUTER CASING ini smulti=fisrifirctlsl OR LINER lifati-fleatkl:': ,_
,' FROM •I TO DIAMETER I THICKNESS MATERIAL
SAEDACCO . 0 ft. 9 ft. 2 in.. SCH 40 PVC
Company Name - • =i6:-INNERCASINGOR-T'LlBINGIri'ottai•niatcWsed-0oapli'�'- ....._ - '
FROM TO ' DIAMETER TRICKINESS MATERIAL
-2.Well Construction Pcs mit#: • ft. ft. -he '
uullirpya/irrable mallprooi/s(i.e.county-Sisae,Variance.II}'2CJc4 err)' '
ft. ft,- 1,t#, •
I ,
3.Wc1I.Use(chccl,well use): 17:3CItE.kN - . , r -•. - .
Water Supple'We1L: - - Furs TO DtA 1tt:TER 1 SLOT ME Tr11CHri$SS 1 MATRRIAt.
.0 Agricultural C]MtinicipaliPttblic, 9 ft. 19 ft.' 2 in. I o]o SCH 40 PVC
®Geothermal(UoatingtCoclliogSupply} ®Residential Water Supply(single] fn. ft. I
©industrial/Conmtercial ®Residential Water Supply(shared) -'18 GROUT"_.-- __ _.:-" :.::.... ..... .. ._ . -....
FROM •,TO• 3LITERLIL EMPLWE.17ENT SIERIQD S ASIOUNT
❑Irrigation - 0 ft. 5 ft.. Portland Pour
.. Non-Wafter Supply'Welk: . n ,. t . . . . .
•dfmonitoring oReos-c1y . ,- _ . -_ -
•Injeclion Well:' fi. ft.
Cl Aquifer Recbarre CiCioundllatcrRcntcdiation •49:'"SANLIGRAVEL,PACltt;f.nppticabtd -_- --- - .
most- To • 1 MxrEstat. n51Pl.ACtxtEN1•min ium
❑rlquifcr.Storagcaid Recover}' I7Salinity Harrier• 7 O. 19 ft. '•Sand #2 -
❑Agnifcr Test 1JSlorninater Drainage .
'ft.. ft.
DExpetimental Technoleg.. OSnbsidcmc Control • •20;BRiLL1NG'LOG7athiektidditional'sheels if-Hecesmrvl'
.
DGeotliemed(Closed Loop) ❑Tracer FROM TO DF.SCRIFTION(paw.lianhcm,wit'nx417tor.' ifi.iraadt•.l
DGeotlteonal(Fleming/Cooling Return) DOther(explain under t121 Reloads) 0 14 8 ft; ' Silt ,
8 ft. 14 ft. Clayey silt
4.Date Wtll(s)Completed: 10-10-23 Nell m 11012 ^� T "
14 ft. 19 f;, Clayey sandy silt. '4-.•�,`w.,.?b»i;` l ' ate✓')
'
5a.Well Location: ft. ft. r' ► j f
ft.. ft.
FacpiiptiivnerNanle Facility 1Dk(if applicable) ft. q. 1i,ti r,p;1, ' ?.:';:J i ar '(
1024 South Trade St. Tryon, NC, :28782 - ft. ft. ' -
Plosi:ail Address.City.andZip 21t REM1iARKS.•
Polk 2 foot bentonite seal from 5 to 7'
.esuntl Parcel ldceaifccadon Nu,(PIN} I, '
!' t
5h.l.,atitiidc and Itingitu(Ie.in degrees/minutes/seconds or decimal degrees: .T2.f crtifirrtion: i
(ifoolllield.one Iatilosa-is sadllci:nl) 1
35.197372 N 82.229868 R' 4" 10/16/2023
Sigtcs -I'�Cc.;lkd Well Cmacrctor P Date �.
6.is(are)the well(s): MiPerenanent or ❑Temporary 1
It).signing this form,1 frerebr or(lily due the u•rlIfsi eras(perei curs»urled in.accordance
with 15,4 NOW.OW,01040 or 1M A'CAC at C,0200 Weil Construction Srnrufards and that a
7.Ls this a repair to an existing well: lJVe-t or DE No oopr of Mk recor7l has&on provider,r)Mc rirfltnrner.
If ips is a,t' ,r,fill avt ROOMY lediator thiction'hlfdlrnr7rlo11 amol e.tplrihl the Aware of the
repair under-Pi remarks recruit or an Me hack ojfigs form. 23.Site Aiagram or additional well details;
You may rise the back of this page to provide additional well site details or Well
8.Number of wells cuilstrueted: 1 construction details. You may also attach additional pages if necessaey-
For madtiple tr(kerppn or 001-maser JUNI:r Irt'lds 0.A11,'with doe sonar constructi n,y ur Oa - .- i
saiiurirone fayn. SUBMITTAL iNSTUCTiONS
9.Total well depth heron-laud sutfaee. 19 • (ft.) 24a. Vur All Wells; Submit this Turin within 30 days of completion of well
For marl& ;cells list di clepchs if different(cnanptc•-e2fSir(oid 2@ IO0't conshiction lathe following:
1
1
10.Static water level below top of casing: (ft.) Division of Water ResourcesAaformation Piacessing Unit,-
If moo level is alcove curia;.are"4-" 1617 all Se ffice Ccntcr,Raleigh,INC 27699,1617
i
1I.Borehole diameter:8 att.) 24b.For infection Weill ONLY: in addition to sending the fomt to the address in
24a above.also submit a.copy of thisfoitn within 30 days of completion of well
12.Well construction method: HSA constmction to the following. -
(i.e.auger.rotary,cable.direct pork etc.)
Division of Water Resourc
es,Underground Injection:Control Program,
FOR WATER SUPPLY WELLS.ONLY: I636 Mail Service Center Raleigh.NC 27699-1636 -
13ae Yield(Om) Method of test: 24e.For Water.S�i irI&inicction W`Its:
Also submit one copy of this form Within 30 days of completion of
13h.Disinfection type: Amount: well con5lrlrction to the-county health dcjxlnment of the county where
constructed.
Faun GW-1 Noah Carolina Ekvanment of Envirauuozun and Natural Resources-Divtion of Water Resotras, Revised August`tl l3