GW1-2021-07141_Well Construction - GW1_20211006

W. N N RECORD \��...:�.,CO �'F1xUC°Tf0 � � Fel tt,tt:raal tdn c>nv:
"Mis.farm can be Awd fttr aide of mwtipla xcfls
1.Well ContractorInformation.
777
John Eisenman FROM DOW11t tr"ON
'A'a Contwor Nam NJ
4439A � R. -
NC LVail t otatacyortbr(itfiDtionl tnnf7er 0 6 LO" '3 GMTR_ " o 6rliiFtl ie.�d ii45 n =
tf t H fFra6
(1C j OM ,� WMHFTt4>EI TntCwwm MATERIAL
SAEDACCO Inc Sgtr•91) 0 ft; 38 (f, 2° in. SCE-40 PVC
to low R WIWI. li 1
DW FROM 70 BtAhtFTM I7tn MAW WAL
2.Well Onstrutthtn trerrnit
dlat& aNib-me urtd_p-01 fig.Cfnf— 5'mt0,If-rnxrr,Irk LV24 er)
3.Wdl use(checlz well ust j:
t:.
Water Supply Well: FROM TO _ -1)1AMXnFt stf/7 W I 71t1C"TW MA't"WAt.
0ASOMItund 11411it3iCiiktlfPabilc 38 R. 48 R. 21 SCH-40 PVC
Mkotliemutt(HeetinsCoOln$"Suppl}) DResideidal Water Supply fsiVe) ft, fL in
01ndusWallCommercial Mesidemial WaterSUNtp fsWed)
FROM lHATtiRtXL- ED1Pt AC M7i9 A i OD&AM0LRV1
�h>ri' ti0n 0 ith 33 (L PORTLAND TREMIE
Nos-Vater So pply Well:
A. 0.
t7Moaritnri C] ac
injection Well: ft.
C]Atjttlfcr Rs'cbmV (�Grout►dctsitcr Retntxl anon t9 D EL ,f: i
f'R tlfAYR tl1t. RtYltrrd i£Vl WIMP
PAA oiler& ,FaidRcmmely oulinity Harder 36 R. 48 ft. SAND #2
C1lLgViki,rc;st ❑�tonttnaterDta gc it
At Werimattal T=1 m►tM C)SAsidt'ttcc Control
1 .R 'Lt• "' tlf sidt8itttivfiti3 ' tttieta5�
13GwthttnW(Clout lAop) bTraca YR.OM I 70 Dxscrttnta�t r.t4anrnon sntrfvnsa, ttG
❑G€oftnttat WN&C60111.Rtwnt ZOtba ftflain Duda alRem&) o >f. 48 ft. silt sand clay
ft. R�
4.Date'gli'ell(s)Completed: 8-2 5-2 1 WellID#B-1
R. R.
Sa.Well lAwationr lL it
Cleveland County Landfill (L ft.
Faciti yl0k,wr Name Facility ll)#(ifMgtkable) R. (L
250 Fielding Rd., Shelby, NC, 28150 ft. fL
Phy3ieal Address:C*—aad Zip 3t:;lt ttrC
Cleveland Bentonite seal 33-36,
C"Ay Pamot ldtntirio0on No,(NN)
5b.i�ittFtitde,xnd it4ngfttdc in aft hnimttestst�ndsbr decimal 4 21 t�t3fcciiknD;
0(well field,one latslo�is sufff cltrd)
�* W 8/30/2021
- -
Si�tnRaf ,�... -v"sl'"'�v.,�.a D.eI¢
6.Ts(pre)tltc v ell(s): - Permanent or LOTernporar}
�}'l ffllUiQ f1�4�LTbiiSV'jf("E;3, rt�.��N'JSaa ..lY�l'lYfAi'EfEfF�R 4i'Y'DS�'�IYTiI.Y
+tlrh)SANCACO2C' 7>4h::.11 , 14QftCia�ratepreedatSw d&d,mdThata
7.is this a repair to an odsft well: Cla'es or iRdNu roc�rhEr m�ri hrzsfi�rn�mvfrk�+o thr nrAt mw�E►
dfift%it rr V41 CdWrnftV(41*r tW E.Plut+t tj.mr*rE ff Pw
"�wirttdr.r 1 ir"etRs mermw or an Me bark of r6ra jr rm 11.Site dlDl*ratn tir at'lditionAl t1`etl�Atc�it#:
You mw use the bade of this page to provide additional well site details or twil
S.Nomberof hells constructed: 1 Wnstrkltt tm detafts You may alto anach-additional pages if Wces'seg`.
For rrraMpdE tbfecrrnrtor nrsn-x+araw atq.pdv urfls t?Nf.Y hVril rd�srtmt t+onsf�rrcNorr,;wu c,�n
sabadtexu m� tIi#1�G1"1 AS 1rL 7tltt^ft©Nc
9.Total wdf.depth below land surroM 48 (R,1 2da. Par All Wells: Sabmlt Ws tonn%vitliin 34 i4sr's of cdtnplttlon of n'clt
Forg ildplewIlslera#40*y#fdr[frreni wn5tractionto the 10tlm*W
10.Static Water level below top of rasing: {i t.) Division of Water ReKonrcts.lnfonwnibn Processing unit.
dfwutterktW#sfihn+Ycutting,9M:°{P 1617 Miff Servieet ter,RaleWNC176"-1617
1 t.Borehole diameter.8.25° (m.) 24b.Flit lnieetlon Wells ONLY: to addition to sending the form to ftaddlem in
24a apace. also Pilrnfil o:copy of this forrawitiun 30 days of completion of utli
12.WCIi Dtt8tr4tC to mt#ltod:HSA constractitn to tt a following:
(i.e.stW,mtaty t 4bia dirms hash ew.)
Dh ision of Water Resources.Underground Injection Control Program,
FOR WAT£RSUPPLY WE LS ONLY: 1636 Mail St nice Culler.RaleloiNC 376"4636
13a Vold(rpm) Method o€test ur-for WatarSapplr& Noteou;`Welis:
Also submit o!! CW of this form isithin 30 dgsof completion of
13b.Dhsinfettion txpe± Amotru: well construction to the county licitth dep rIment of the cunt♦when:
constmc(od.
Farm G%V-t 1490 Camllna tit sf fit Wwwnt mud tbnaW Rewwm Mwi=ionof Wata R4sotron k%-bcd At t Y81#
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