GW1--00812_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD For Intorno!UseONIN,;
This formcanbe%sed for stngkar multiple.wells'
1
I.Well Cuntractorlttfolwation: ,
"tS..WATER ZON ES-
Robert Miller FROM. TO • 'DESCRIPrlON
Viell_ComtiactorNanrq, • tx.;'_ . ^ .pr .:., --- R,: ft, I 1
2675A a1-..ea,`,1L. 7' �rra i) .ft. ft I J.
NG.Wcll Contmclor Ccnifecatiari Nwtlici JA 14 3 '1' 2024 AS.OUTER CASiNG(fir utniti-eased"ectts)OR-LINER(iroi ncabk),
FROM TO DIAMETER., I 111110ENFSS :1TATERTAL..
SAEDACCo in r7r.-'ir.1 `'a,...
. Con "'�'"�::9 Uw Y 16.4INNER CASING OR.TUBING(ceothcrMai ellscd-looi►):
yr:my.N;lmp ���.h
_ Ut'• IO0 {FROM TO- DLLMPTTRR. ' TthICKNESS ALATERL4L
�2.Well Constroctirin Permit it': . . 0 ft.-ft.- 27 ft 2 ' ,in. 'SCH-40 PVC.
fist oft appliinbfe!roll pcimits(Lr.County;Sort;.Vafiamre,117fa 0clt rfc,:l: . '
It, rt., tp. ..
3.Weil.Usc(checl,nellnYej '. t7.SCRIEN '
Water Supply Well: . . FROM. TD -314M/.TCR •'St.OTSPX 11It(Kfl1M5 I MATRIOM.
DAgticultinal • ClMumicipal/Public 27 •R. 37 •R. 2 in• I .)10 • SCH-40 PVC
®Creothetma((Heating/Cooling Simply) ®Residential Water Supply(single) ,ft' f• (n, I;
1lndustiial/Conuitercial ©ResidentialWater'Su ::ta:GRVDT : - -- .-_ -
PPh.(S1Elltd) • FRO\I^_ TO -srATERFAL: ' EMPtACE51ENT NIMROD R A3101nTr •
EIthii)I,Ttion . - • 0 'ft.' 23 ' 'fG Portland Poured
• - Nou-Water Supply Well:, ' • R.. • ft
ElMonitoring • . i]ltccovcry .
Injection Welt? R,• ft. - 1,
CAngiferRecltarge IGlomidn:ucrRentediation t9:'SANIt1GRAVELPACK(ifapplieab4Y. -
'FROM • TO' • 1fAT'RR1A1, k 1 LRMPIACV01:31-MI Hon
l3AgnifcrStoragc and Rcem'et3• ASalinity Bonier 25 f.. 37 ft,. Filter Sand #2
pAgtuifcrTcst • . DS(oumndtcrIhairlaC• . : l '
R. I I .
. ❑Experimental Technology DSubsidcncs Control
'2n;DRILLTNG'LOG(altach-oddltior(aI sbcebr ifoeccssan•l.
DGeodienna1(Closed Loop) . • t7Tiacer• .FROM•-• To : DESCRIPTION twb@.bard:mon:witwkutruc.:gran,re.rt) ,
OGeotltetmal(Fleating(Ceoliug Return) •t7Other(explain udder.#21 Beatniks) . :ft. R'. •I I
ft.. ft, r . .
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4.,Bate Well(s)Completed:'12/14/2023 Welt lD MW-39
ft. ft.
Sa.Well Lacatinn: .ft. ft
Gaston County Landfill R R
Faclit}•,'Ow•ocrNmnc Facility IDk tit-applicable) n - R, .
3155.Philadelphia Church Rd. , Dallas,. NC, 28034 . . R. rt.: .
1,1ry3icaIAildisss.City-aid$ip :21.RltitARKS l
- .Bentonite seal from 23-25'
County I treC1 idetilificilton No.(PIN}
Sb_Latitulic and"Idingltade in itcgrics/minutcs/scconds ni•decimal dtcl - 22.Certifreat(nn:
(Moo field,orrc)a,1ooSlg'tmffli•lcid} - I
:f.,� 1
N Wf°: 1/9/2024
Sigmtuio,of� tcret .-rr^l•�:s ^.-•--- Date
6.Is(are)the.tcell(s):.xiPerinanent. or:' i7Temporary f di' (1 [ J
lh•signing,lair.omr:'1 hereb•certify Mi s the wells war irre t n:so f eel%R orco tlancr
with FM MAC 02C.0100 or 15A NCAC 02C 409 Rill Construction Swixlards and rhai a
7-Is this a repairtu an existing WclI: E]Ye. or KIN° coprofMir rrcord lion(teat pmearol eq.ilk%rll oiurrr.
l%h(s'Ir a wok/ill oatkrrc;avt trcldcotumrceleoiuf rraurtlon and aiplabr the ruuore of the
repair tinder#21 remarks lectiau aron the bailatilt r form. 23.Site diagram or additional welldefarts:
You may_use the back'of this page to.proside additional well she details or.will
8.Numberof wells constructed:1 instruction details. You May also attach additional pages if necessary.
For rn id plc infeeilan or anti-9rarer apply wells ONLY with the same construetlotr,pit can [ •
=Omit one farm. ' - SUBMITTALINSTUC11ONS.
9.Total tcdlilepth below land surface: 37 -• (R.) 24a. For All Wells; •Submit(his-form Iwitbin 30'days of completion of well
• •Foramid&'rcliclist all depths ifdifferem(example-3@200'and 26?'10l0) fonsttlictiont0 the.foltossing;. •
10.Static water level below top of casing: (tt,) Diyiaiun of Water ResourCO,IInformatian Prucessin;Unit,
theater level k above tat i;ate"+" '1617 Mall Scr-ke Center,Raleigh;,NC 27699-1617
11.Borehole diameter:8.25" (in,) . 24b.Fnr infection Wells ONLY: in addition to sending the form to the address in
.24a above.also submit a copy of this font within 30 days'of completion of well
. 12.Well construction's ethod:HSA - constnidirin to the followliig: I'
(Lc:auger.rotary,cable direct push etc.} I• I
. . . •Div(sloa of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: .1636 Mail Service Center.Raleigh,NC 27699-1636
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fl3 I Yield(>pm) Method-of test: 24c.•Fof Water Supply St Injection Wells!
• Also submit one copy of this form withllt.30,days of completion of
fl3b.Disinfectiontype Amount: well-constntction to the county health department of the.county.whote
constructed.
FonnGW-L North CarolinaL)tpartnrcntofEmirmtuttnrand Natural Resources-Divislonof WaterRmatrxes Revised Argti t2I)13