GW1-2021-05424_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD Aw litcnml Un ONLY:
'Rib fora+coin be ersod for sftk or toulliple was
1.Well Contractor Information: \
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John Eisen-an r9old im arscmPYIox
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Welbl;ontmetar Ran* a„ ;
4439A n
NC Wcll Con merorCviifkm on Natitcr Q L1 i«atl1 R CAclNti nrYtfouNiorrilaiCFh 01t;TINF.R, `8ci►li` ;"
r 1PROM I To nrAM TER TRK19TSS
anATm unAm.
SAEDACCO Inc �\ sr�!�c�U!11� (L 1 48 fL 6 ia. SCH 40 PVC
Comimoy Nam
FROM TO DUMMR IMMTM MAIrRtnL
2.Well CAnsttncdon Permit t 0 (L 65 k 2 hL SCH 40 PVC
1 in id,arum lr writ permits l t e:Cwrnhr.S&TV,114damr.ftikan n rx)
fL tL ln.
3.Well Usc(chedc well ace): 9`
Water Supply Wdl: iR M mAt+i►.M St t nM- . MAWITUAL
DAgticultumml I:�MunicipallPttblic 6S R. 75 fL 2 n. .010� T SCH 40 PVC
OGeothermal(fieatingtCooling Supply) aResidential Water Supply tsinSte) �. to'
nu i&(iRt)m'
CJindusttiailCotrNrcial OResidetmat Water Supply FROM TO aiwrermmAt: "TPIAC'rM sT1"r litlrllon&AMOUNT
ElIrriotion 58 ft. 3 fL AquaGuard Trememie
Non-Water Supply Well: 3 il. 0 A. portland pour
Mtaionitoi oRecovely
IQ ors 1Ye11: rl, tt.
0 Aquifer Rica itge (3GmundVM(cr Remodiation
ra M tATttRa t. kMrm.A ,�� : n
10-
C)AqutfcrStomxge and R.ecq" OSalinity bonier 7S 0. 63 iL SAND #2
O OS
Aquifer (ommsaterbrainnEp
OExprdmcntal Tbchnolog 0subsideanee Control
OGeoltmean►al(Closed Lapp) OTmcer YROM w TO M RS Or av r tia u�mrR )
OG tm eotheal(HeatinglCoolilig Renuu) OOther( in under#21 Remaths) o M 35 fL SANDY CLAY
35 ft. 48 rL parr
4.DateWdl(s)Qmpletcd: 9-16-21 WdIID#CA-33 48 iL 7S ft. rock
t.nes SrL Well 6m: It. (L
tt. (L
FwflkfO+a=Name Facr73i}1DA df alrplicahlc)
fl, ft.
1315 Outlet Center Drive North Carolina 27577 John,_ , {t O,
P10-W 1 A&Imm City.and Zip 71.:111 J!t' K3'
bentonite seal from 62-58
Cam} Parectte"Iricetionwo,(PIN)
Sk L*titbdcaud t,angkode in de mimmtm/seeonds or decimal degrem 22,Certification:
((twell Mow mic wons is s�dficlrra)
11 W 9/19/2021
Slsmta of r u t v. -` Date �.
&.Is(are)the n'dl(s): ZFermanent or OTemporary Bs rtg+>r„a rhtr jw,a rh �r'». �, '�t«e�e`: i temrnurrrrJ ar a�rordcrirtti`
0A/-$A NCAC 02C stmdanfs andshoo
7.Is this a repair to an odsting well: MVes or 17No roff ofthtr rwmW 1wbem pnvikkd to Ow hril anwr.
t/thta 119 rrp dr.fill out Lvelm UTH consrnwifm i0rimskn and explain du txrtrree of the,
ropalrW der t'2t rrowrks.rrraion or an itr bark of ehu form. 23.Site diagram or,additional well detalta:
You nua)'use the bwl-of this pope to provide additional well site details or well
S.Numberof tiieiis constructed: 1 consnuction details. You may Also attach additional paw if necessaty.
For iffoNpte tn/errk+rr.or arm-U%w supply UW15 ONIX n fth die$MO.eonsp urtFarr.vox cx�
9.Total wdt dgnb beMW land sarfaM 75 (tt l 24a.Fbr Atl Wefln Submit this fann within 30 d*'s of completion of uvll
Formobipfe wettsliti all*p4a i/differrnr fertrorpte-3@20V'o rn'2@J(MY) cansts u lion to the foilowirV.
10.Static water level befoiti top at a amslmm (fit,) Dit ision of Water Resodreea.Information Processing Unit,
If twor 4 art at obove ediAg.rue"4" 16171VIsfi Service Center.RA160,NC 276094617
11.13ar+ehrttc diameter 12/6 tab.E2r iniecNon Webs ONLY: In addition to sending the form to the address in
24o above also 9ubna)t a oopy of tills fbtm within 30 days of completion of well
12.Wdl cuBStracft"method: HSA/Air cominmction to the following:
(i c.atrw- Division of Water Resoore xs.Underground Mjcctiae Control Program,
FOR WATER SUPPLYW'ELIS ONLY: 163E Mail Service Center,Raleigh,NC 276994636
13a.Yidd(gpm) Method of tat 2.te.Pnr Water Soppy&Inloexmn'Wells:
Also submit one copy of ft form ihtthin 30 da)•s of completion of
13b.Dislnfectinn hpe:, Amount well eon5lnactitm to the cotmhr health department of the cm",where
cousncted.
Farm GW t Noah Carolina Dqwuncnief En im►=4 and Mmsl Resomoes-Division of Water R l n-bed ALCUA 2013