GW1--05380_Well Construction - GW1_20240909

, WELL CONSTRUCTION RECORD Forbv;rntil l .cONl V
Thu form con be ussd for single or miullipk«cols
1.Well Contractor Information:
1 II.WATER ZONES
Scott Hunt, Jr roost 1 to j ors%RImOS
N'c11('otitactor Namc O. fL
i
4561A ft, i fl,
NC Well CmnrnctarCcnificalion Rustier 1S.OUTER CASING(far maWi-eao d»Oki OR LINER tW an health)
FROM f TO Mvytrtrit THI(KtYis,, it iT't Rttl
SAEDACC0 ft. 1 ft. ia.
(',,,pram N.,nw It..INNERCASING OR TIMING 4aamberoatckiwd•lunp)
i MOM TO RIAMETER TOOK',T.S., MATT.RI ll
2.Well Construction Permit k: 0 R, 25 ft. 2 . SCH-40 PVC
lln all applicable well pemuh(i.e.Comm.Mare,Variance i,...-:rare.s -
R. It., in.
3.Well Inc' (check well site): I7.SCREEN
Water Supply.Well: Y*OM TO DtAMITrR s1.0T9111 ' OM kites j MATYn14I l
OAgtwultural OMunieipa6'Fuhhc 25 ft. 40 R 2 nr 010 SCH-40 PVC I
OGeothennal IHeadng,Coolinit Supply) OResidential Water Supply(single) e. R is
OIndustriaUComnlercial IlResidential Water S[glply'(shared) IR,l3RO111Y
FROM TO MATERIAL_� EMPLU E_R TMT METNOR a AMOENT
❑litigation ft. It.
Non-Water Supply Well:
R. ft.
ftMonitonne ❑Recover _ _ i
Injection Well: R. R. 1
LI Aquifer Recharge ❑GroundwatcrRcnucdi.aion IRSANRNtr'iAVRL PACK(Ifatgdie*Yel -
1 now 10 sisrtaist. vertu-revs-MlctOnn
0 Aquifer Storage and Recovery ❑Salinity Barrier ' 23 ft. 40 ft, sand 2
❑Aquifer Test ❑Stonmsatcr Drainage
-
n. ft,
❑Eapcnmctiial Technology ❑Sahsidcnc C'onaml
2HI.DRILLING LOG(attach addiiiesal whech if ncccsarJ_
❑Geothermal(Closed Loop! ❑Tracer roots to RES(RIPtio\,anli.r.hanks...,rnl Mckopt,min lee,eae.)
❑Geothermal iHeattng!Cooline Return} ❑Ocher letplain under 021 Remarh I 0 ft. 20 fly red brown silts
20 ft. 40 ft white tan sandy silt
4.Date Well(s)Completed: 8-23-24 11 ell IDu TMW-2
R. ft.
5a.Well Location: h. n. I E 'I ``r L.+V f f�;, 7"'
p I1 s/ jw
Statesville Dollar Tree H. II. S E r v Fecllls(lws net Nanac Faciliy-IDI!(if appltablet ft. M. 9 2024
2189 old Mountain Rd., Statesville, NC, 28625 ft I fie"—
it,1v:,.„
i.i�.- r._,
1.r
Physical Addicts Chy.and Zip 21.REMARKS _
Iredell Bentonite seal from 21-23'
('.lolls I'ereclIdcmdicallonNo tPINI
5h.Latitude and longitude in degrees/minutes/seconds nr decimal degrees: 22.('ertlficatinR:
(if-Reif field.one I:a.loisj is sidfkt:iai
N W' '!.`f17V 8/26/2024
Sigl»i r::en cci 4ontractor Crate
6.H lure)the**elks): 'Petmaneet or RTcmpMirary By signing fhir fame,l hereby certify that the wylifs1 iwlr(*VW)inrarm u ted in ireottdmwx'
WA 154 NCAC 02C,01f10 or 15A NCAC IY'C.0200 Well Canstruyhou Sradardc and that,e
7.Is this a repair to an esistieg well: Dees or KNu ,„r,•'t flu.a „nl has lira prawairS s'she well mine,.
/f Nib a a repair,fill anrt maws w et1,unarm II,W,.Inforrwwhwl and a spine the mane of Ow
repair under 121 remarks m-ri<n, n an the bait of thu forum 23.Site diagram or additional well details:
You ntai use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 :unit Ict1O11 details. You may also attach additional pages if necessary.
Fur maltrplr ioierrn»i,n m.w•crrcre-..uppls wells ONLY with the soon MAW'uera.n va CM,
subunit emr PM. SUBMITTAL INSTUCTIONS
9.Total well depth below laid surface 40 (ry.l 24a. For All Wells: Submit this form %ohm 3u days of compktion of well
For malieplro.elf„ur,,ua..oth f,teS•,,1;eme,g4.3e200'and2@llwft construction to the following
19.Static water kiel behpw top of casing: 30 (ft.) Division of Water Resources.Information Processing Unit.
if Weiler h trl in ubuvr,a Sin x.a•- . 1617 Mail Scn•ice('cater,Raleigh.N('27699-1617
I1.Borehole diameter:8.25" (la.) 24b.per(niceties Wel,b ONLY: In addition to sending the form to the address in
24a abuse. also submit a copy of this Ions within 10 days of completion of well
12.Well coesernction method:SSA consitucuun to the following.
I c.ricer.roan.cable.direct push.etc 1
Disisinn of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Seri ice Center.Raleigh.NC 27699-I6J6
I ia.1 imid Igpml _ Method u1 lest
2k.For Water Suppls&InjaYliun R'clh:
Also submit one cops of this form is Mon to da_ssof completion of
tilt.pisiuil tinnhoc: Amount: well construction to the county health department of the county u-here
conistntctcd
Form OW-I •.,ii u(aroma l.Tannriu of Eau riomlt<tiu aid Natural kesources-On was of Wiley Rmoticm It...iced August 21I I 0