GW1-2021-01604_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD
1 L
For 1mcriml Usc ONLY:
nis fhon cnsa.be used ror.sigk or multipic+nails
1.Well Contractor Information:
,14.R'i['EEtt`?pIV IDS
John Eisentnan FROM TO Mt'Rar'ttt0!t
Weal CottttacTot hamc U. ft.
4439A
i fi. f4
NCWcJSCon=,torCenifbmtionNuma5rr t Ot1T£R:G4fi.1;GG' +�YinuTii t"s UiC1.ilVER<t AcYFit�l
t Tittlbi TO I ]PTAIMPITER Tni h'ESSi MATMAL
SAEDACCO In_c 0 M 15' ft. 2" e. SCE-40 PVC
Company Mow Iii:lAill �t ,' R 81Nfs ilttftlfit, ��
FROM TO DE►t1 M9 TRiCIG1,SS MATERTAL
2.Well C'onstrwtinn Permit#:
List all aWir-a&r%v(1 prrmlrs 0 r,C'aantc.Srurc,Varicir ,r.Pfetttritt,etc.)
R. ft. iji.
3.Well lrc(ebaeh-well crag):
water Supol}Well: MOM to , axtMFUR I VOT SIM I �ttrtM MAMM.,
lD.AgrLoiltutal riMitnicipaliTublic 15' ft. 29' ft. 21, iri. 010 SCSI
-40 PVC
OCkolkirnal tNeatingACootiitg Supply Mesidentiai Wetter Supply(single) FL in
©it>dustrial/Commercial OResidential Water S Mt'(sham)
FROM TO MATMd--J L UMPLACKMENT MCMOD A AMOUNT
Lion 0 ft. 10, rt. Portland Pour
Tenn-V►tater Supply Well,
®Monttc3riA CJilecnt�e ' R' fr,
ittjeetiott well: h it.
MAgtiifcrltcclkirp ri-GroundwatcrRenwdiatiati ;ih.SAlai }�ItA,' ACl►'"
❑Auuifcr SlmSc and Recoviv• Milinity Barticr 131 t. � r�r, � � >�+tt�Y�s rsi�cip To MATE
3 fr. 2S G. SAND #2
❑Aquifer7'est 1351ormn-atcrDmioa'= fL ft
0EVrdmcnmI TochnotoM- 0$ubsidence Cn> 1
;3tr.�Ait1iA,sl'I31h7O` aclliaditifiltinal3katait` ar•`'. ._. r:
❑Gbathemud(Closed Loop) t7Tracei FROM I TO DFWaWrrO
❑Geotheimal(Heath ooliita_Remm) 00ther(e c lain undet#21 Remarks) 0 ft. 30' ft. SANDY CLAY
ft. ft.
4.Date Weff(o Completed, 3-25-21 Weil M#10-1 n. tt.
e }'
5a.Wdl Location: h, n,
Carolina's Consolidators tt. f1
Fay-U%,mrName Facilth JD#taf�a bublci ft ft. � H
d1ft T T � �-
245 Orbit Rd., Statesville, NC, 28677 ft fi rnrnr tfi0[Mll
Plnstd:+Lsh m--City.:wd Zip ;2t CIHAItF► i'u i_
Iredell Bentonite seal from 10-13'
NK•al td:ntitt iitioo No,i;t
5b.Latitude tude and Longitude In degrrestlmimttWseconds or decimal degrecs. 2L Certification
tbfueff redd.owe:taboo is stdnefzad't
-" 4/l/2021
Sagmhrrc of
6.U tat0 the wellls): EPermanent or oTemporar.
tzn�rnrrmb bn a ordmce
'. .i)2M well07,1axnsultan 5ranliinf'i cuwlala,tt rr
7.Is this a repair to an eatiifing well: a7YO- or K No iVy n{rh.t r"oni iprrs 6c.^r4 pmrirled ra;the mr1l.•,nawn
If This is a repir1r.fill rAvr.kmrmw dvAdex,airaelt the er!rrvre of ril
rrPair amfrr ov remrtrfs seefio a ew rm thx hrx•S a(MiN farm 23.Site diagram or Sddhioual well details:
You may use the back of Utis page to ptoOde additional well site details or well
S.Nun&er of wells constructed: 1 c onSlttietian details. You racy also attach adbfulional pages if nocessan-.
For orri.ltrlate lgkx,roraw er routs-nvari-r ash I ivrits ONLY 0th rlm anmr e#-Ms saint.yen v((0
.W-Niritcorer.fame ,SUB11 MALINSTiltMONS
9.Total well depth below land surface: 25 (ft.) 2aa. For Aft >,`etts: Subndl flees form withirt Act days of cwntptetiott Of tteli
For srarlt ple wells less 4TUArprtlrt 3@200,crurl Me IM) conamrtion to dw follo ilkq:
10.Static water Im-el below tap of casInZ_ M.) Dhision of Water Resources Information Processing Unit,
Lf„Yury lrvrl"4&tmr,rtsrrtx.am"}.,
1611 Mao Service Center.RAldgh.NC 27699-1617
11,Borehole diameter:S.25" lilt) 24b,far inicction Wens ONLY,`Ire addition to sending the form to the address in
24a abo%,c also svbu t a color- of this foma within 10 dal-s of Completion of well
12.Well cntwiructiom metbod.-BSA em stnrction to the follotv-ing:
4i.e.ats ;rotor+°.c9b1�diaec8�st�cic.F +
fthlou of Water Ressttrces,Underground Injection Control Program.
FOR WATER SLTPLY WELLS ONLY: 1636 Malt Smite Center,Raleigh.NC 27699-1636
21e.for Water Su &injection Wells.
Yitfd lgpm) Vlctbrid of test: E
Also submit one of this form U4114n 0 days of Completion of
lab.Disinfection thpc. . - Amount.. ,_. well construction to the cmmt)- hcahh depauuuetri of the count♦•►situ
con.ont cd, C
Fonn GW-t hasrah fotmlim Ek-,m umof Emi muoero;w d Nau"Iteaoutan Dhi;lom of Matey R&souina Gc:iccd Augat?ari3