GW1-2021-00313_Well Construction - GW1_20210312

WILL CONSTRUCTION RECORD For fnserml Use ONLY:
Tins farm can bcowdtorst ltornauliftwells
1.Wall Contrwor I1tt0rnnatlon:
I I C IWINA xAN
John Eisen-a- FROM I TO Dr$CRIPrr®Y
Woll Contractor Name n. tt.
4439A R.
NC'tl+cllContmctorCeriffomionNnnbcr s.iliTiER t3tli►r `fH1�aKaciltieA Ttili litti�b'
VROM I TO PTA;Nr?Mit THKVI%E35 MAI"TAL
SAEDACCO Inc 0 fL 15' tis 2° In. SCH-40 PVC
Conartmp'Nome 16.:1: hT (1R T11B71'TG ►Crta7d l
VROM I TO DIAMFTBrt I Ttr1CA'rm I MATfTOAL
2.Well Conshvedon Permit# n, rfi in.
tiv art opptiredsfr sari permits ti-c.Goanrv,sting.Ynria�e,l�eta'ai rrr.)
3.Well Use(chock well use):
Water Supply'Well: FROM TO 1:DIAI�tr.TiWR MATS17Y I T1ai M MATVAIAr:
DAgdcultulai l'Stmniticipal/ltablic 15' tt. 40' it. 2° 1% .010 SCH-40 PVC
OCkotbemul(He adrigtooling Supply) Mesidentiai Water Supply(single) ft. fa.
®lndusariallCot»mercial t7ReSidentiat WaterSttppfs{slaatisd) ti tiltt)
FROM MATRRW. SATPtACT.SmT A mil i mi touNi'
❑lrn Lion 0 rt. 10' (L Portland Pour
Non-water Supply Well:
aMorritori C2ltecoti �.
Injection Well: n. tt.
C3AouiterRecharge MkoundnvtcrItemodiatiwa f QM- r1tA.:
O ifer Stv and Ra=t 13saliniv Hamer vs 1rr rATr r nr rt a. rr�ct iaertt n
� '�` 13 tt. 40 ft: SAND #2
❑Aquifer Test 13S1onmvKar 0ruinnge
n. ft.
QEVerimerrtal Teclmoloa OStdisitkrrce C4ntral 2tl nRn,?tnrttxuoc �iiact: tt8 fldriilt st+eeistt+
1310eoiheftnai(Closed Loop) QTtmcft FROM 71) nticMMON artr.arrsdt�atiirhock n carte raa)
❑Gsolhennal tit. Remtu) ❑otber ain Under#21Remaft 0 n. 40, r1. silt sand clay
R. R.
4.Date Well(s)Conpleted: 2-26-21 Wdl3DaMW-s
So.'l`Well Location:
Circle R Store fl, It.
Facr7it},tlnvnevNwne Facility]DO(if appiicdbte)
ft. %IAR t r,pp
R. 2�2
8036 Moncure Pittsboro Rd., Moncure, NC, 27559 ry, tr,
I lull
Pk-skel AddR m City:and Zip7,
Chatham bentonite seal from 10-13' V8 ���
(mnnty Pared Ideolir'Kalian No,WIN)
Sh.Latitude and t ongituric in dcgneeshnimrtc0secontlsor decimal dogrttics: 22.Certiftestio':
lit u>»lt Bold;pne l rttl6r is 1�dflcicrd)
N W ', 3/1/2021
51 ,z of •��i:'i: rt, Dalc
6.Is(are)the vvvil(s): zPcemonettt or ❑Temporary At ggn&R ohs
u4A!SA itrCAC ASC t SAG Mtti,{120p tt�t!Gnaapn+�aftzn 5tand4rda and iho;a
7.is this a repair to an exixtin well: DYE or it%) ruff ofd,G nvWhasbem prmiiled to Ow nril akgw.
If Ali is a rtyrntr.flit oar 0AMV'a wrll cowrnnrtkm Aafgrrrxrrlan and WWI?r/ie Mrs re of the
nWir an der 021 rmarkssecrron or.rm.dw hart of M&form. 23.Site dhWam or additional well details:
You m4 use the barb of this page to lirm'ide addiifionai Asti)site detals or well
S.Numberof ssclis constructed: 1 crostmetion details. You amy also attach additional pages if amemly.
For drmtple f*aJon.or mri-weer spph a etls ONLY nith thr dome coirsuv ilm''.vow can
caGa�ur gala foma $j1DMFCi A1. 193-C
9.Total wdt depth below land surface 40 (ft,) 244, For AI► Wells: Submit tli(s forth v'ithin 31D daps of completion of vm11
For miitripte wIls 40 all dew l/difi'erent letmipte-3@ 200'eW 20-.IWj construction to the fWlawirW.
10.Static water hn-tl below top of eminz (ft.) Divismn 4 WSW Itcse"Ices.InformationProe"Mrig Unit,
111MMP kvet lr A toW c4tft We`+ 16 ice Center.Raleigh,NC'276"4613
11.gnrchrttc diameter 6" (ia) 24b.Fbr(OWUn Wells ONLY: In addition to sending the form to the address in
24a abve. also submit a.copy of this form within 30 days of completion of well
IL Virdl construction method:Air construction to the fallowing.,
(Le.roper.milary,tablet dim a pnsh cm.) Division of Water_Resourca.UndeMround Injection Control Progymm.
FORNVATER Si3PPLY WELLS ONLY: 1636]Haft Service Center.Raleigh,NC 276"-1636
13a.Yfdd(glim) Alethvd of test:. 24c Fair Water So MT i i!gc dfon«veils:
Also subrnft one copy of this form within 30 daTs of completion of
13b.bisinfeetion,1)'PC Amount: Nrcti construction to the county bcalth dcpsrtnnan of[het counly where
Faivn Qw+l 1oNt Caralln s Dcparivacm1 lfEmirunarni aW Natural [e-mail] n Of.WBiL't REShIICPS -RC�i'iS�d Aa1 t IOlZ