GW1--03850_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD For Ina;rasa:1 ;ONI 1
The form can be Inca for single or imrltipk oclls
I.Well Contractor Information:
14.WATER ZONGS
Stefan Smith PROM I TO D'si RIFT ION
Well Cotiraclor Name R. ft.
rt. : ft.
3576A
NC Well Contractor Certification Number IS,O(ITFR CASING tfor multi-rased celloOR LINER Of applicable)
illOSI TO DI iMETFll T 11(10TSS HATr11M
SAEDACCO 0 fl. 37 ft. 12 ia. SCH-40 PVC
Cousin N.mu lb.INN1R('•A_SING OR 11 BING ijsetbenraf cloud-tout)
FROM 10 DVi SIFTFR rill(10N0:S1 MATTRI II
2.Well Construction Permit N: r El. It. in.
pig all apply ably sripennio ri.e.Cawun.Parr.Variaare.h$ eh-.) -.-- ,
rt. ft. in.
.3_Well I se Iehecl,well iisel: 1 17.ti(RCEN •
11 Ater\upph %%ell:
FRmI to MAMMON ' !ft.OTSIi1 Tuu revs. NI 51IMul.
37 ft. 47 la. 2 ia, .010 i SCH-40 PVC
•1;:n,tdtutal I_IMunicipal:Public
UGeothetmal IHeatin 1Coolin St h I I IRe.sidciutal Water n, h. to 1
R 8 IpP Supply(single)
UkldustriatComniercial I IResidctw:d Water Supply(shared) 1L(aOUT
rROM ( TO MATERIAL. g1Ql_Nl FNF\T Mt:MOO A NNOI:NT
Dlrnpatton f, R.
Non-Water Supply Well: R. 0.
Ktslmmonng ❑Rceoven'
Injection Well: n. f4
Aquifer Recharge ❑Groundwater Remcdnaaion it SANb1UTAVELPACK Of applicable►—
°Aquifer Storage and Recover ❑Salinit}Barrier riotsm MstPRw. RMM.NI FVe"\r MFTIIOII
35 R. 49 ft. Sand 2
❑Aquifer Test ❑Stommiecr Drainage R. ft.
❑Expenmaual Technology. ❑Subsidence c'oniml
—
2n.DRILUNG LOG launch additional.heel.if accesvn t
OGeothennal(Closed Loopt ❑Tracer FROM TO DF-SCRIPI)O\a tits.h,nj,r«.milli.I.as pr.'r. r"we.rR.1
OGeodtennal IHeating,Cooline Return) DOther at(explain under 021 Reatlsl 0 ft 40 ft. Silt
40 ft 49 fL Sandy silt.
4.Date Wel bsl Completed: 4-11-24 %%dell ID"TMW-1
R. ft.
Sa.Well Location: ft. It
Wellington Property ft, ft,
Factlm•'OnaerName Factlin IDaiifaeplicabkl ft. ft.fl i j �• i
1419 Gaston St., Lincolnton, NC, 28092 ft.
rt. •
Physical Mhos.Cfay.and zip 21.RCMARKs JUN 2 8 2024
Lincoln Temporary well
(-aard:, Parcel ldcnlafr:alb,n Na IP1ti1
1Tn'v.T.E.41,1 ill"' i Mein
CMG,,304
5h.Latitude and Longitude in degirev'minateslsecneds or decimal degrees: 2,.('crrifcatiur:
of cell field,one IaiJna,g is adlics nt1
rd
35.474165 _N 81.230751 W 4/22/2024
Stpnnoea'ofCc.,f nimctor Dan
6.Is(are)eft wef(s): Permanent or riesporary In.batting rho tarn, 1 hrrrbr certify that rhr'wilts/our turret cemetrwxd in accordance
warn I A4 NC.AC 02C.0100 or I SA NCAC 0217.0200 Writ Castnrrpn,SNorod vAt and that a
7.Is Ms a repair to an existing,w ell: OYes or ION* ropy of rho rev r.rd her,N.,a il.rided to,he,.r11.r"•nrr.
f'thb u a repair,fill ow kna.no a.el.,aurru.taM anfortnatt to au'sl rvelaat Ow rumor.,(rhr
repair rustier S21 remarks wanner or am Mr butt of this fora. 23.Site diagram or additional well details:
You may use the buck of this page to pros ide additional well site details or well
8.Number of latch constructed: 1 constmt'lion details. You may also attach additional pages if necessary.
Fat mains*asjrrrrra,a aw,-ajar,auppt,bells ONLY nth the we cerutraeenoa Wb coo
saftn,r an,r(urn,. SUBMITTAL INSTUCT1ONS
9.Total well depth below lard surface. 47 (f1.) 24a. Fur All Wells: Submit this t'onn ssuhtn 10 days of completion of cell
Far maalrrple writs last aft depth,rfdrflr'col acaanapfr 1st?OW,aad 20'((Nit umstmdtan to the following,
II.Static water ks•el below tsp of canny 41 (ft.) Division of Water Resources,lefortnation Processing(sit.
If natrr!et el a teharr a oohs.der'•♦" 1617 Mail Service Center,Raleigh,N('2 7699-16 1 7
1l.Borehole diameter:8.25" (hi.) 24b.For Injection Wclb ONLY: In addition to sending the form to the address in
24aabase. also submit a copy of this loran within 'kr days of completion of cell
12.Well cosairuct st method:SSA collslmction to the policing_
ate auger.roan.cable.direct push e.e.I
Di%isiun of Rater Resources.l:nder-kruond Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail San ice(enter.Raleigh.N( 21n9q-InJ(
I3a.Weld blperl ___ Method of test _ . 24c.Far N iter Nnppls &Injntiun Wells:
-" Also submit one cops of this firm wilhio to daysof completion of
IJh.Disinfeetion t2pc: Am nwnt: well construction to the cottmy health department of the counts wheat
constnnt:trd
Fenn OW-I 'Joni'Carolina Dcpnnra t of Ens mimeo(and Natural Resources-Dis cos of Water Reo rors Res axed Atrgu5t 201 t