GW1--03834_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD For IiicrnalUscONLY:
nos form can be used for singk or multiple wells
I 1\ell Contractor Information:
II.WATERZON[5
Scott Hunt, Jr Jf .ROM H) D['f('RRI1011
Wc11 Contractor Nanw , 13 ft. 20 ft, tacky red silty clay with sand
4561 ft. ft.
NC Well Contractor Certification NumberIS.OtI'I'6R CASING(for mshi ra+rd wens)OR LINER of epplkahk)
room TO miMine Tlin't0rss msTTalsl
SAEDACCO h. O. is.
Campion Nana IS.INN[RCASING ORTURINGtgeothermalchned-t.utpj
t71OM To ' 10 01111R sells AS1NS MA TERI St
2.Well Construction Permit M: 1*40301351 0 R. 10 rt. 2 tri SCH-40 PVC
List all applicably urn permits fur.County .Srmr,Variance livered(r1..1 - -,
ft, it I- in.
3.Well I se teheel,well use 17.SCRUM
Water Jupph 11 ell: racist TO Otasirn 1 slot sin' THI( KNI S MATRRISI.
OAgneultutal OMunicipal,Public 10 ft. 20 ft 2 io, .010 SCH-40 PVC
ft' ft. in.❑Geothemal(Heating,Cooling Slimly) OResidennal Water Supply b(single)OMdustrtal Comoieicial OResidernul Water Supply(shored) 1t CROIR --
/TIOM TO MATERIAL EMPLACEMENT METHOD 1 AMOUNT
❑lmftation 0 ft. 6 ft. portland 1 trimmy
Nou-Water Supply Well: rt.
RMonitonng ❑Rccovcn ._ t
laJection Well: It h.
❑Aquifer Recharge ❑Cimondwatcr Remedial',1, t'.,\'D(.ItAVRLPAf usallcs14)
❑Aquifer Storage and Rccosen- ❑Saliniq Barrier ""' Mariam. r.MM:tr rvrNT MtTIM)n
8 ft. 10 ft. sand 2
❑Aquifer Test ❑titomnt,ncr Drtill ore ft, ft.
❑EspcnmaMal Technology' ❑tiubsndcrmcc(burro( 2111.DRILLING LOG tatted atlnlNloaal sheds if asccssan) i
'
tx❑ othemrll(Closed Loop) OTrdstt FROM T(1 DESCRIPTION ttoV ma r,4dmcw,tnit'nw•4 n gr
oin..re..M I
❑Geoihem)al dkatmg'Cooling Retumt DOther te'plam under 021 Remarks) o ft 13 ft red silt
13 R. 20 ft, tack red silty clay with sand
4.Date Well(al Completed: 5-10-24 Well IDi -01
IL ft.
4 .
Sit.Well Locatwm: fL ft. ""t►`lI j:''/E 0
PPG Industries, Inc. ft, ft.1..„,1,,, t n,ocr Nato,: Facility UM(if applicable, R. JUN 1 8 2024
940 Washburn Switch Rd. , Shelby, NC, 28150 R. A, ifitellAreilf#t Peer,ftosely t
sk
Physical Address.Cits.and Zip H.RCMARKS DtfliCl'j ,
Cleveland Bentonite seal from 6-8'
('most) Parcel Wear-Mimi No 1PINI
Sb.Latitude and Longitude in deurresiminurra ucvonds or decimal degree': 22.('rrtificati as:
Orwell field.one lat1oss is std It):t.ui I
• ,
N W Ifllf �i,,�%� 5/17/2024
Sign4d: Cenlk i iwell Contractor Dote
6.b Dank the wrlllsl: lOPennanent or temporary (A*nine Mil form.I herebo ratify that the welts,our(urn.I c0ntrbnrtrd in ariort{an,r
with 154 NCAC 02C,0100 or I 54 NCAC 02C,0200 Weil Coautro(rion Standards and dicer a
7.Is this a repair to an existing well: LI es or X No ropy of this won'has hero provided to 1h.•urn owner.
If Ali as a repair,fill awn known well...norm ran information turn!u splatn the stature of the
repair under 12l remarks cession or On the bait of this form. 23.Site diagram or addkissal well Iktails:
You may use the beck of this page to provide additional well site details or well
8.Number of wells cousins-fed: 1 con sinlction details. You relay also attach additional pages if necessary.
For multiple rn}e,t#ut or a,MI.ic tr•r twpplt s ell,ONLY moth the amine cuaaraelfam.Vaal arto
sabrnt use form. StIBMITTAI.INSTUCTIONS
9.Total well depth below laud suttees 20 (ry.) 24a. Fur All Wells: Submit this (form suthun ltl days of completion of well
For mahiplr cells list t0 deprh1 ifd$rrenl e.•uonpfr-tai•?rlrr and?ar hint constnictian to the folknin t
Ill.Static water ksrl below top of cast.{: 13 (ft.) Division of Water Resources.Information Processing I nit.
If water liarl a as. mr.astat.ate '." 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter:8.25" Oa.) 24b.For Irtjectiou Well ONLY: In addition to sending the form to the address in
24a abos e. also submit a copy of this form within 10 days of completion of well
12.Well cowstnictw)n method:I4SA constmction to the following.
(iv.auger rolars,cable.direct push.etc.(
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Crater.Raleigh.NC 27699-1636
13a Field(ti pml Method of test: 24e.For Water Suppls dC Injection Wells:
Also submit one cops of this from calms 10 days of completion of
IJb-Disinfection hpe: Amount well construction to the count health department of the counts where
constructed
FontGW-1 Nonh Calcium OgionnrruofEmurr.n.-n .Id ,ituralRemmeea-DivisionofWerectResotrces Res iced.August2013