GW1-2022-01415_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For lrftnol Use ONLY:
Eh6 form coo W UqM far sin*or M tigtle-Tt'dis
1.Well Contractor Information.
24�{Sj►tER N ;
John Eisenman FROM W MW;RtMON
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4439A
NC Well Canlmc rCcniita WnNimb r f,'r,Ot[f1RXAMR§kt Olt l+iFsR: ahk
FROM TO DrAvrMR TAtC1 NFf.S MATERIAL
SAEDACCO Inc 0 tL 80 it. 6 jt4 SCH 40 PVC
CAt*'irrt KantC ]t6l R- )B1N� '.-:"IittiliaGt Corr =_ _ . s,
FROM TO DMINUTER I TnICr€i`,TeS3 MAMMAL
Z.Wtsil Con-traction Permit tt: IL
14st all suplirutd r urelf th-unto(ir.Crunane,Twr,t'orl owe,l+Osrdnn ere.)
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Water Supply Welk FRO%l Ttr.;.; . trtmiNW-4'az*10T firl,V TltiCtt'1K55 inAtsRIAL V
DAFkaftitral t-municipaTAtUIic a- rL ln,
12GeDt MWI(UMiTOCo011%St ppty) 1 fR%ulvtt l Water Supply(sinee) IL 1"
Dindllstrial/Co m mial DRssideendal Wamr s"t '(slt md) =
FROM TO &LATERAL FRIYI:ACHMENTIrlIMOD&AMOUNT
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Nan Water Sapp$•well:
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®Aquifer Recharge oGroundwater Rcntediadon t9:ShN l li lsA l 1tc _ .
<aAgatifcr Slomp and Reeocciy oSalinin°Bander - M R. Ti► - tt MATRlrtai,_ P7Ffpr A[T ltrii M€SNOn .
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oGeodwrmat(Closed Loop) oTr�x FRoM 110 1► C1nrTaoN 46w,hattatm:fuilamcA ft o ste
oGeothemnal(Hearin&aCooli o Retuni) 130dwr wqAain ender#21 Remarks) ti. ft.
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4.Date Weill(s)Completed* 12-17-21 W dl lD#MW-1
io.Well tetesbn:
F�:ott x>urr,Frrt m t c l ,�tn it,
109 Hinnant toad NW Goldsboro, NC, 27530 ti. tQ
1'fisalArmss CiCy.urdZip 2tii Etilal,lltlfer.";, _
Wayne Open Hole from 80-135
0AUMV MMO, M14irwatiotr No,(Fttit
Sb.Limaide and Longitude in or ftimal degrees: 2L Ccrtif-nation:
(if xa liew*ft lal;iom.b srditCiztg)
W ' 12/26/2021
6.tafateltLewcll21: 10Permanent or DTem ra A ra�r s� fs arc -a
( t>D I}' N ax�nin, drdi�ae,a r rf ti. j w ,i.:c:rtr rnrrnrrfrrl irs eaawJrloruti°
uvrhif.4�C,AG11C.•��-�.�-f• 1.ri ��.+/�`i4�ilCoxatrrrrafoirStr�ei'zrrefsun�'rlutru
7.Is this a repair to an tAwtimlicit: oyes or oNo copy of tAis r*Nwnl fires hrtra pff lided rr aler awll tenor
1'fMis"a repodr,(11104F krrartmm well awfflury'eaa tarfrasrnrataM annul expleabtalu Awtior of the
repair writer r 21 remarks aerafem or m the bark n fthiv form. 23.Site dtagram or additional well details:
You may use the backs of dus page to provide additional sve l site details or well
S.Number of wells constructed: 1 cmisttuslion details. You IM also atiach additional pages if necessaly.
For."Mirdple i*slink 40 Welk ONLY Wrh Me some eomkas"t,w*e om
mwnir awe jrorv. SUDNIMAL INSTUCT'f©1ylS
9.Total welt depth below land surface. 135 (l}i) 24a. For.Ali Well &ibnrtt lids form Within 30'dtlys of completion of well
Fora,-,allfi rle Twills ltsr arll depbs if dllfrFew 40'r4ra)jPf(c-p@-'O'9°arias Mi'fp F') construction to the following-
10.Statle water level below top of casing --._---. Division of Water Resources,Information P rrc AsinE Unit
ltwaar+r level&MtOtV edsfrae,ava"4-" 1617 SIail Setviee Center,Raleigh.NC 296",1617
11.Borehole diametcr.12/6 funk 24b.For Iginggn R6pj v ONLY: In addition to sending due forth to the address in
24a above. also submit a Copy of this form within 10 days of completion of u>ill
1.2.Wdl construction method;aSA/Air constniction to the followulg:
tie.aiga rarefy.cable dhxt pustt ctc_i
Division of Water Resources.Underground Injection Control Program{
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Service Center,Rakfth,KC 27699-1636
13a."idd 24r.'I<or 41r!# SEE&&tniection Wells:
Was) ,1letfrnd of that. Also submit one cop' of this fomt vvdibin 30 days of completion of
13b.Di>3lafixKlnn t3pt Amwrnt- < we11 Constnrction to the county'health depamu:w of the minty whc=
y. �a Y _.a_s cotistruatsd.
Farm feNa-L s'�011tl Csratiira lkpdnarttr of F.ae°fmnmenf met`lantml R�ouroes-i)i��+en of Rr9ter R Rc�'iud Att�rt4f 71913