GW1-2022-04878_Well Construction - GW1_20220525

WELL CONSTRUG T(ON RECORD FbTImemilUsr.ONLY:
Ttr l"rnt Can tra aWd fhr sin1;1a qr rnttltiitla a clis
1.Well Contractor htfortnalion:
.WAVAtER WIN
John Eiserttnan unit) 1tr nF tit Rtt?rt0)i
leeil Comniclor ft. ft.
it. ft.
4439A
1�vuTce`cxsrvcu���ut. �lKeltStOlttYNfRti1`�i EiEa6tei>=
NCtVcilCaiUrac;orC2nifi�itionNunhcr 1 MOM 170 Dt\stF"M T81CKNFSS M ERIAL.
SAEDACCO Inc SCH-40 PVC-.,
tow,INNER t'A SING OR`i't3Bth6`{�aiit j'j—aM v ciuddc
d.onaluutL tiaurF rrrtt�:-
FROyt TO Dr101 1ER TtAMNE:SS MA TERM
2.Weil Construction Permit#:c}•y�Fi:xlzrr rscii,vrnritx ff.c.Cuwus.S.rrtr,tixriacrr.It�JELACdt rxr./ E��
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3.Weil G-c(chrckwell rase): 17 INCR N =
aterSuppk Well;- Ft- ! Tar n AMETM gr.(rrsvr. I iruluul4rs I NIATPnlni.
Clrtgti€tiiturtl Ci2vtttnicipxl)Wbtic 30 It. 50 h. 2" hL .010 SCH-40 PVC
17Gcodletn131(Beating;C061ika snpply) Cl oidzutial WnwrSupply'(single) «. IL in.'
01ndusaiallComoteic'r,11 011csid'cruial Wirer Supple'(slaird) ¢tt41`� ro ;•raTEneu ) 2t]P[tCEF1i�T%T MQ10 S AS10ti%T
E7h7i lion 0 t1. 24 ft. Port and Pour
N1ot1Ajr,7ter-WnpplyWell: ft. ft.
2100 it0ring 011ccovery
Injection Weift fl` ��
c.It P�cut : <0Aquife RCcharge 06rotindunicr Rcmctiation L9 s►Nnt eviyita •FROM 1n mvi- M. P:11PfACF_IrBVTUMMrt
❑Aquifer Srotage and lt=ovcry O."linity Barrier 28 R, 50 ft. SAND #2
MquifcrTcr l CislormiumerDminagc ft. ft.
LIEs(rtintcmnl Tee hooloyt y 0Sabsidcthc Control 1'2uz ItRi1.L1?�f:i>(1G"(aftacli ailditlanA!'firer+ifnccc nr v=>..
!]('eot[ra:nnal(Closed Loop) OTracer FRO%1 I To orscit irnq rtteb.hardness willotkh x.atin,rra.60
❑Gt�otltemnl tFiwtiru?ICooliu:.+Retain) L1011tcr(e.xplain under#21 Rear;o") 0 (L 30 ft, clay/ sand Y 91
30 ft. 50 ft. rock
.pate welts)Congtletcu: 2-26-22 Well iD SW-s x It. rt. MAY 2 5 2022-
Sa,well Location. it. it.
Broughton Hospital it, (4 a MT i13ry
Fu,tlii),r7asrax fastx Factlit)ID90raappli abie)
1000 s. Sterling St., Morganton, NC, 28655 t R ft.
Ptr;sralAddrscCitc-and Zip �I R btARit4 -.,
Burke
24-28+ bentonite seal
_ _
t:nmJl t'=J ld-nd li Aim No.MNl)
31t,latitude and[nngttuile in dc�tseslm[aute;?secnDOs ur dccina tl do rt*css 22.Certilicatian:
of t+elt 1'std,rn>L L•.triol�is srtiliei.�)
5/1/2022
Tr ` Date
SrrtLtrt flr
G.IS9are)Citetcell(s): XFetmanent or ElTempor ry
Bp s:r•:ih�rt�:a•ffixr,.: .�•_.=r,if.Ru.:r- ,..r,,..��„c::r••••"-rtnrrted tar cxa:vrtic.�rc
rIvrd
ecoularch44 an
trfi;i!'1.44:•6G :.f.•r-s'-.^'-•� t:r.�.. t:'.0 13!l lii•lf uu-dnr is ti
7s.is this a repair to an existing wcU: DYec or ENO c'trfn^n;tfi%:rr,^crrrYp h,ts Er"I t•460+fu!rz rur:ri+:1 a4rgrr:
rp di fS!t a r k!•dr filf stilt(r'om tcc its oviiioioa infortilar,'tnt 4a?d*ivellam Or nim-4,of riff
ra rufrutul.�r 021 re:naxrAssi aicr,orcm thr hr:c(.of tfris farm Yo Site diagram lit or additional well details:
You Wray rise the back of tivs p€tg:to provide:tdtlitiotl:tt wc+t1 site details Of rVet[
a.Number of drelb constructed: 1 - constm ian detaits. You ntav ai5o attach additional page's if trxess-atp-
Fi r tn-INpare Ca r e a-tcw r;,i ph 4veffs ONLY--iih tee•same conusor•dorr .m=_:a, SURN111TAL IN C'i'11C1`IONS
s::nnur ane fomt.
9.Total well depth Itettov land surface- 50 tit.) 24a. Fair All Wells Submit this foam %vill in 30 days of conlPtctiota of licit
For tnuhlltfe rrrlfr tier art d'7 nhn if',4ftisroo lcxrirnpfe-.I'-2,W)'ant 2 i00) conatniction to the faltawin-
10.Static water level below to of camin , (R,) 11ii ision of Water 1Resanrres,Infrtrmation Prni'emin+4 Unit,
p L6t7 Mall Service Center,Raleigh.NC 2-1699-1617
i/}r:i:r.+In r:tt stvn'r stasia+:;.asz'"+
11.Borehole diameter.6" (in) 2-Ib.Fn en fit 'fiv ONLVdi In addition to sending ft Corm to the address in
24aabitce. also sublrit a copy of this folm within:;0 days of completion of oell
t2.%Ve11 construction method;Air consitnction to the following.
#i.e.wi,mr.mury.c3b1c.din:%1 rush-<10 Division or'Water Resources,Underground Injection Control Program,
FOR WATERSUMV WELLS ONLY' 1636 hfail Srndce Center,Palft t,NC 27699-1636
't#ctltnd of test: Zle.For Water Supply d►1n�43ain Wells:
I3a,Yidd(gina) - -- - Al_u submit 011e copy of lhis ftitm uilhill tt)days of c01tg11eti0tt of
Snell constmction to the conn4v Health delrailment of the coitntp ai--rc
Ponta C:LV-1 f�tsnitC�roluul t7+:lr:trtuxnt of Enitmrtn�na atui`antrar ft_arrrrscti-Dit•siAti n('1Vater R�uttn:� iln fs,�d atigtts?_Mil?