GW1-2022-04905_Well Construction - GW1_20220525

WELL CONSTRUCTION RECORD For lrtzrnal Usc ONLY:.
This rd"?i can h;used ror_singlc or rnullipk-wefts
1.Well Contractor Information:
I.S.WAIER ZONLS
John Eiselrmart FROM To. DFtiC61PT1ON
NkviCcitxardnrNano
4439A
NCi4eliContraciorCcniGcslionNutnber' 1S.OUTER CASING fformuftl-vivilnr.Ns1ORLINER(ifa Ik—1
FROM To DLt�1tTFR Tir1Ch�FSS �UTERIAI.
SAEDACCO Inc ft. ft. in.
Caitgt:tfiy.t�'mic M.INNER CASING OR T1'BING(Umilcrual cluscd.Imp
FROM i TO I DIAMETER THICKNESS MATEML
2.Well Construction Permit#: 0 ft. 24 A. 2" SC$ 40 PVC
hw all i:np rabre tt r1f ji.rntd,i(i-e.Cbtrnrt,Skae,lfariarrr;1 jerdM qt-.I —-�-
'
3.Well,Usc(check well usc): I7.SCREEN
Water SupptyWell: FRosl 1.70 oMirTrit r.N►rsr�s- Ttncxxss I 51ATFRlrsl.
L7rlgritinitural i7lviuni:ipal;711UIiC 24 ft. 34 f►. 2 in• 010 SCS 40 PVC
DGebttu:mtal(110 II&Cooling Stq)ply') QRcsidential Water Supply(single)
in.
❑111dostTiaUCommer:ial l7Rcsidcmial Water Supph•(slkvrdY IS.
GROUT
FROU TO ALYITRIAL- i E?tPLILCEb1F\TNCi1rOUfiASIOII\T
❑ltli lion 18 ft. 0 It. PortlandPour
Non-.Water.Supph•.Well:
H%lonilorin Olkccowry
Injection Well:
❑Aquifcr Recharge OGroundaater Rcnicdiation 19.SANDIGRAVEL PACK fit t Ilicabtc)
•FRONI :ro Ntnrr:Ri:u.. tNfrLAcr.u:vrsttauoo
OARuifcr Storage 161 Rccovcry ❑Salinity Bariice 34- ft. 22 ft, SAND #2
❑,aquiferTcct. ❑Sloan aterDrainage
❑F. rinicntal l'o:hnolp [7Suhsidcftcc Control
1 20.DRILLING LOG(allach additional Skeels if ncecmnn I -
❑Gothennal(Clusetl:Loup) ❑Tracer FROM TO DE5CRUMONrtolr.Laranl�n,-WnKkft in.ire.ctGl
❑G otliennal(IleatinerCooline Return) ❑Oil kr(explain udder t121 Remarks) 0 ft. 34 ft. soil
a.Date Wcu(l)Completed; 2-22-22 Wcll i6OMW-39C (t, it. �
. .r
59.AWII LIICath►n: ft. It. -
ft. MAY 2 �'t ?
Facility(}urcrNam Facitity.iD;(ifaypliVablo) f1. ft.
9 4' ��lr,•;r.o.,a
3900.Electronics Drive Raleigh, NC Rake County 35., ft. rr: pp
Plnskal Address.Cin•,and Zip 21.REMARKS
Bentonite seal from 22-18ft
(:antst): 1'an;0 U-ndilbc:Uion No,(PIN)
Sb.Lat:W6 and Liingitifdc in dcgrecs/minutcslsectinds or decimal do ntics: 22.Ccrtifcnti0d:
(ira ell_fi0d.ore la1,7orra.iz'strfliei rn)
N W _ _ y - 2/22/2022
Sr mturof 7 n,� r Date
G.G(arc)thcacll(s)::X+Permartcnt :or -OTemitoran•. ,
fat s:gnirrn wirer find: !uf rq ! , ,r.,e:.1.rurJrruercd iir rsrnnrarcr
a•irA 15A NOW 02C �:ti�-1.:;'4ri: lC;0:(Y)ll�•i!Consrrgrctkrn SrnrLinitls arirf ilia tr
7.Lc hL%a repair to an existing o,cll:-. OYcs or KNO rmr nftlrir rrcarrf l as(nvn l rnrfifrrl rn`ibc tlti tl r,rrnl r}
/jrhri it a nptdr;flNcnrr bnbirr k rflrr..runrirlon nrjOh:L.wrion Laid eXplant the narnre ofrhe
repsairurderd2l re tarks-acclim�or ar dtt bark-aj whir fnnn. 23.Site diagram or additional will details:
Yuu t laF.-usetl'liackoGtl(ta pag .lo.proNide additioteiCNiell site"details or well
S.Number of siclls ironstnicted: 1 construction details. You ntay ah attach addifional pages if necessary.
For owthiple infeerion or am-srmu r nrppl r IMIS ONLY nVrh the 34114C C4M51rttcli(m,NOR Ctur
auGuritonr form: SUBMITTAL INSTU .TiONS
9.Total swcll depth beloli land surface- 34 (ft•) 24ai. lair All Nrdls: Sub»ul this form within U days of completion of Nell
For)utlple wells flu 0-1depthr ifdij•n•m(craw:;pfr-.-@2rX1•and 2@1(y.)) eoiistnution to the folloi ing:
10.Static water level below tali of casing (ft,) Division of Water Rmources.Information Pruccsaim,Unit.
If srd"er revel is above wslqz we"+" 1617 Mail Service Center.Ralcigh,NC-27699-1617
I
It.Borehole diameter.8 (iu) tab.Far.fnlmlinn Wells ONLY. In addition to sendin_s tit2 foml to the addre,,,S to
24a ab&e. also submit a copy ok this funs within.3b days of completion of utll.
12:Well construction method:BSA construction to tlic folio%%ing:
(i.c4ugcr Telar „cable,direct psk.ctc.)
Division,of Water Resourcr"I.Underground infection Control Pttiigram,
FOR WATER SG'PPLY-%8 ELLS ONLY: 1G3G btail Seivice iCentcr.Raleigh.YC 27699-163G
l3a ti clil.( im) 1lcthod;nf test 24c.For Water Supnh•&:kijecti4n Wells:
Also subnut onC'copy of this form ►tithiit 54,daysof.contpletiotiaf
13b.Disinfection type: Amount:. well-constmction`to the county Iliealth department of tiro couruy iv krc
consirt.mcd.
I
Form Gk%'-t North Carolina Dcpanuxut of Ern•irotmilm and Natural Ri sources-Diyslon of WaierRT--WCrs Rc%ised:uXgst_N)I3