GW1-2022-01321_Well Construction - GW1_20220124

WELL L CONSTRUU N RECORD For E nml Usc ONLY:
This fona an i tie used F"stigkc of 9m1t1pte Wctls
ri.Well Contractor iltfortnation:
44: xA lUP1>�
John Eisenman FRONT 'ttl PFet RtPtte}Y
'll'eil cortrulam Name R. Pt.
/L tL
4439A
13:{iOTFftGr[Stlrktitfdt'"'`til�t�drstff�k�RL filfat' b
NC Weld CanWaor Ccniftestion NIMA)C7 FR VI I To DIA NETFR 7t11C[NTSS V 7£HtAt.
0 (L 20 fl,. 2" hu SCH-40 PVC
SAEDACCO Inc
- _ -
('mtgrtnl•t+�lrtw I lN�1ER INt�:OR�R�IPfiG- �rttisifi" d•i <-� .�_
FRONT I To Dt1M1IETER 'IHIEWititE3S .... MAIERtAL
2.Wtll�+lnstruet�ln Permllt#: R. tf.
last uffaWficr$fr k-r11 prc'rmip'(i_r.Catrlat%Sturr•t'ariaaee,lffaCdiOrt etc,i
3.WEf€V-so(cbetlswell D,SeI: -
�'stet Supiit}Vl ell: FRONT 't* D1AntPa�R : sti0't'SV 7iftCWxM-4L sn
DAglicldtUM 0MUnicipallpttblic 20 ft. 35 2" in 010 SCH-40 C1Getltbetlltatl tHeating/Coolin¢Soppls•) DRsmidenttial Water Su�li}'(single)
rl.DindustrialfComllmitil OResidelltstlWaterSnpph•(:jKiredY fAG [FORAA'fN '. EiN1+E,wt.'t:'bfEVfaiLYttOD&.UN�DGtvi`
ohTi Lion 0 k. 15 fL Portland Pour
Noo—Water Supply Wen: R
®Moniloring ❑Rwctne - _-._.
O FL
njetllon WE
0Aa uder Recharge I30roundymm RcatrdWian : but VFW.PA S tli tstei =
iN arI tY1 S7AC' ti. AC7ur�e�akir"rlfCtfi
MAq"iifer St4mgc and Rccowiy Ilsolinin°Battier 18 R: 35 fr, SAND #2
oAquifcr lest o$tommatcr Drainapc ft. ft.
OE'VcTimetwal Technology 0SO-011•nce Ct n"I gtk Dltlti3�Ntt Cat...,tt ddl6aditl s�eet317�xsra
oGeothenni l(Closed Loop) FRONT TO Dnt'RrrMS mleir.bardttem s"ttL t<tam
� Am44ta..,_.
oGeotteanal(Ffe�ottelGdoltteRet nt) Dfhicel6�r lainunderQ?I Retna► ? 0 rt 35 (L siit�sand clay
rt ra
4.bate Well(9V Completed: 12-23-21 WdI ID#MW-2 ft, fL
5%.M?ell l aestivin: tL ft JAW2 4 RE
Antioch Food Mart (L
Fac1WV#i'vr,orrNa= Fac0%t}li2R(if fampl cnble) tt h.
2940 US-64, Morganton, NC, 28655 ft. u
1'fivcW Add=%.City.and Zip YIz Ett s-
Bentonite seal from 15-18'
Burke
I a 0ql t-,rrco bUigit' tiori No.(PLN')
Sb:i,a itudie and to itudc In dc9reelz{tninitUAcconds or decimal de grew. 22,Certification:
(ifnell Said,Laid: W11c*4d)
12/27/2021
w
�t�tf�of 4 •ti V-Vf t 1Flt1i� 1 "`a"
6,is am)the wdl(iy EPerlranent or �Tetn ra
( ( � i>v �' 6?sr�ir��rMr far�,r r• •ri !ice r� . .r...v�.:r re t�avnrctrd ae aixa*rrLzrir�e
ua't3 1_fh NCWO Tf~ +' " + Cie- t=.[t2i}ft{4V0 54owrrrai'c cwnd Av a
7.h."a repair toanexiNdagIvell: Ves or CiNo arrjhreVtJufrWeoniharlhccuFrnrdtlrt'tnrfarstw!«rauxet•,
df trta it a r erlr..f+lt rRstrrVnrt v e1d c nrrstrtn tta�n e�rfvrrarurr�emd r-sFlair rya ruar€rre r+t rnr
rep fr under A_1 rcm arks xer iarr or rm the&T1 Qt1Ux formr. You
Site use h b additional t well details:
You testy tlsa tti:back of this page to prtn^id:additional well site details at isell
8.Number of welts comtructed: 1 c:o(t motion details. You may also alfaeh addifiotW plate if tta a 01Y.
F-or mialdp!e 1gky-Tkm or rum-wier IWIF uriis d7i1LY wIr1a rlte saaar tanatrmllovr.parr c eaa S ti111►1Cf�A�[1115�tTi T70Ni�-
xahuret cmr form. -
9.Total wvU depth below land wrfam 35 24a. Wells: Submit this form--"Akin V days of completion of welt
For nitiltP,alr x:vlt fir rr11 dd�rha 11'dit<'aralrt lc�xcriatPtr•z��'�il'crrut 2@!(7tPy crso.5tnutit�o tcl Mlle folhsw9q�G;
10.Stack water to-el below top of casinw. (ft) Division of Wster Resources.Information Processing[fait„
ifriwear lrcrlla txnatasi+tg r+±r„r" 161711tail5cr1'icle(Critter,italcipb,51C 27691460
t1.Bof ehote diameter 8.25" fin.) 24b.For lnicetitrn Wct1s ONLY: in addition to sending tits fotnl to the address in
24a above. also submit a cops';of this fear within 30 day°s of contpletiron of ticeil
12,Well COMIrUCO rttl tbod;HSA c-wistnmtion to thef©llow�i89:
(i.e.zugm.roan'.cables dhw vask ctc:l ifhision of Water Rcsourcetr•Underground tnjedlon Control Program.
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Ser+i&,Center.Raleigh. li'C 276"4636
13a,Vidd(gpm) ,!hind of test: 24c-For Water Santill&tniecthen!!fr'ldls:
Also stibmit ate OM'of tttiS fptm ►t thilt 30 days Of completiali of
138.tiisinft�ciian tr _ Amount: ._._____.n._.� _ iAreti comorlfctian to the county hcalth dcpartutnt of the county a,'h M-
.©nsttuctcd.
Fann fill-1 NonL Camliluc ticpsttmiemr of Emmwurgm aid Nunael Rasowocs-ok"n of Water Remutin Revised At -4013