GW1--07218_Well Construction - GW1_20231108

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„.. — ' 'ELL CONSTRUCTION RECORD , _10 \ Par haernalt*ONLY:
- This form can iv wale,/single ea multiok wells \.D
1.Well Contractor Information:
:•:IirTER.ZONE& .:' -. • •--1 1. ' '• ' ' .
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Stefan Smith - NOW TO .: DESCRIPTION
Well Contractor Nam, h. ft. 1 I
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ft. ft,
3576A ,
;45:•01lTEItCASING`Hdi,iitalt1Leasedivellst ORIINOttitsili.tkablett;...-.., - .
NC Nvou Com:actor antis:at ion Number
EOM.. 1 To ' • DIAMETER I 111ICKNESS • MATERIAL - .
SAEDACCO . 0 ft. 1 8 It. 2 I tin. SCH 40 PVC ..
CiunFuty braise, •/6ANNER'CASING.01111n3ING:teetittieirinal efsiSeittotoyz:',",: -.
FROM To , DLAMETER. ' ITIICTiNESS MATERIAL
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2.Wall 'Permit IP:
List 4ty applicutde well permits(Li'..Coin Surtd...Variairre./)a-dm Jr.) . • ---•
.11.- ft; 'ilk. • . .
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3.WeR.Use(checl(Well use):
• •Water Supply.Well: Fawn TO nivarviia SLOT SIZE I TRIERNESS MATERIAL
8 ft. 18 ft.. 2 Si!. 1.010 SCH 40 PVC
ClAgriculttiral lISfulddiptliPliblic.
To, ,
C3C.leoiltennal aleatingleboling Supply) ClResidential Water Supply(single) . ftft,I
M CJI
18 17 GRO112..._..—--- ..._•',17..-....:'J,:,MInstrial/Commercial C:IResidential Water Supply(slo..red) • , tolit. ' TO-- . MATERIAL • . E1-IPLACi5104TMETIIOD&A.MOUNT'
- . Ellnigation. . - , • - 0 ft. 4 ft. Portland. . Pour .
•. NoniWater.Supply woii;.• .
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&Monitoring •• - . ., ElltecoveIy- . .., 1,
•Injection Well: IL . ft.
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1:1Aquifer Reeharite mindWater Rcmcdialion . ,..:19/SiNtliGlIAVEL1'ACK rifiapplieiblia.-7-==.----''--' '-'-.-.;--7,-;'-:-.',- ---:-- '-
To .• . MATERIAL • EMPLACEMENT ME.TDOII
.ElAnt*r.Siorageanil RecoVefy D$olinity 13arrier ' 6 It 18 ft, Sand l', #2
ElAquifOr test EIStonnwater Orainage .
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ClExpitimental Tochnoloa.. •LISubsidettee Control
z310MILLINGIOGliiieddilliidrilitKiiiiiiticiissaivY.' • . --
CICIeottiennal Mused Loop} OTracer - Rost • TV . - IIESCRIFTIONImbnItarditc...;sonhtitkopt.-mili f.ite,dm
OGeollienitaI(lIemine/CoOling Return) 00ther(explain under#21 Reloads) 0 ta. ' .12 ft, Fill ',, • • •
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. 12 ft. 18 ft Silt 1 I 1,.J•.;• '.:--?. -? - :. i f:..`.-7 F "",
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. 4.Date Well(s)Completed: 10-1072 . Welt 1114114F1 ft. • • ft. I
5a.Well Location:. . IL ft, t . NOV S 2023
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FaciliiyAgivocrNinse • - Facility=1DP(if applicable)- -
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' 3.024, South Trade-St. , Tryon, NC, .28782 ft. . '11. - .
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' . . , • . Physical..AddreSs_City,andZip .:111HEMA1IRS- - -- • • .-' ' . -. ' : . - • ' -- . '•' • '
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Polk. • • 1.2 foot bentonite seal from-4 to 6' • -
'Conon' Parcel idetaidioil No.(PIN)
Sh.Latittide and Langitude hi dogreesiminntessciiittils or decimal degrees; 21..ctrtificatimi, •
• Wool Iteld;one latnoug is suft.1‘: nt)
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35.197469 N 82.229989 W •„ 1; . r„... . -s I ' — 10/16/2023
&gra- ofCe.. led Well Contractor ! ,Date
6.1$(are)the well(s): qppranationt or, CITettiporary 1
lly*ding di*form i llereby cerfify that/hi ire//(24 was 1)Lartri ettnyoutzat to nvrordEnce
with 1 54 NC4C 021C.0100 Or!SA MCAC:172c.41.2ao UWS coniitilcaou Standards mid An et
7.Ls this a repair to an existing well; Elites or ileNTO• awry of Mk rtvoni hOs In.'at provided to AI$14,11 owner.
If Mi.Cis o%WY,Moat finown well ecywriKtiowitticirmlon apt/ortfint rife Ohnare of the ! -
repirir under 021 nivideks.tivaicira dr r.vx dig hark of di&for*. .21 Site.diagram or additional-well details; . .•
Yaii may use the back of this page to Provide additional Well site details of well
8.Number of wells eottstiitcted: 1 • cOnsfluctioit details.'You filay ALSO*Melt additionalpgesif necessary.
For: pre irtfallon or notwnter supply irtrils ONLY with the srtto cinestrurtion,yOM coo • .-
-rani'nit aue film/ ' SUBMI1TAL INSWCTIONS i
9;Total W01400111 beton'lands facet 18 .01,) -24,a. For All Welts: 'Submit dais fain within 30 days of completion of well
For ornirlpie Weas-Hu off drinks If dPrent(exarople-3g20tr and 2.a,MO constnectitA to the.following: .
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10.Static water level below top of caSing: (ft.) Division of Water ReNOUroLl,Informatitin;Processing Unit,
If ware,kW!)II abOVe 0.1.Si ag;1111."-4-.. 1617 Mail SCIVICE Cente'tr,Raleigh,NC 27699-1617
IL Borehotedionieter:8 (in.) 24b.!gilt kisetion Wells'ONLY: in addition to sending the form to the address in '
24a above_also submit a.copy of tills'form within 30 days of cotnpletion,of well
12.Well construction method: HSA construction to the following:•
tie.sip-.fanny,cable:direct nosh.etc.; • . .
. Division Of Welter RESOrces,Itattlergnund.fujection'CoittrOl Progrant,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Centei,Raleigh.•NC 27699-1636
24b.Folli;'ater Stlyn1V.it InAecthin Wells:
13o.•Vichl(Ow) Method of test;
. Also'submitA one copy of this forinl Within.30-days of comPletion Of
13h,Disinfection,typi.q Amount:., well construction to the.county health Idcpartinent of the county where-
• , constructed. I
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Fenn GAYA. . . . • -North Carolina Department or Environmenaand Natitral Resources-DWidon oi Water ReSotic Revised August 2013
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