GW1-2022-05476_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD For(nterrrrrlUwONLY:
T Iffs farm can Ix wwd for singic or multiple ivells
1.Wett Contractor Information:
kAVA•TER2ONES
John Eisenman FROM Ttr p"SCRiMON
W0I Comrdoor Nano
J
4439A
NCIVcllConlnuclorCcdificatioiiNunber 15 OUTERCASiNG'fo"rrnufltcdsednctls'•ORtiiNER(tf'a"tka6k
FROM m prNIETt&R Ti11CiCNESS hiATERTAL
SAEDACCO Inc 0 it. 10 (L 2" iu. SCH-40 PVC
CojiVway Nanic C INNER'CASiNG'ORrUBING r trlM'rBrat etuud fda'
FROM TO DBNIETCR THICKNESS M.4TERUL
2.Well Construction Permit#: ft, ft. hL
Lixf oll,:p-P1fcvWr well pomirx fr_r..Cmmh'..S••mc,lrurimxr,fry'ecdo 1.rfe! im-----
in.
3.Well Use(check well use):
WaterSupphy Welk FROM To urANfF•TFR SLOT-17% Tt11CKY1sS I M,ITFRIAL
C1, Lukultutal Cihtunicilmifl'ttblic 10 ft. 25 ft, 2" In, .010 SCH-40 PVC
Meothemtal(Heating/Cooling Supply) L1Residenta•il Water Supply'(single) ft. ft.
CllndustriablCoi anercial ©Residential Water Suppy'(shared) ;tB::GRQ[1T
FROM TO RATERLiL EMP[ACENIENT SM-MOD&AMOUNT
❑Int loran 0 (L 5 (L Portland Pour
Non-Water Supply Well: R. rt.
®Manitodng pRcco�rry
Injection Well: ft. M
EIAquiferRccharge l7Gronndnater11cmcdiation 49.SAND1GRAVELd'ACK'(if
FROM -to MATF:RrR1• FstPrA'nis..r Mrrol un
gAtlnifcr S(orage all Recovery ❑Salinity 13arricr 8 R. 25 h, SAND #2
❑AquiferTcst t75Wnmratcrlmimigc ft. fi
❑E.perimcntal Tcchoolobj' ❑•Sabsideacc Comml
108.D1tIGL111G'I OG'fatlach adiFitiondtefieetslr race¢scan+
❑Creutltenlal(Closed Loup) oTracer naval TO DRscltrPnv�ttnwr u,rnr ea.,,tmekw n :rama
OGcxrthermat(Heating+Cooling Retum) E10dier(explain under#21 Remarks) 0 fL 25 ft. sand clay
rt. ft.
4.Date WCH(s)Canrpleled: 4-28-22 Well iD#MW-11
ft. fL ,
Sa.Well Location: (L (L
Circle IC 4660 f4 ft. c '
Facilill:,UivncrNnnic Facilil� ID;:(9fappli.ablo) ft, ft. -----�- L I a ----
1513 E. llth St., Siler City, NC, 27344 it. fL ••+�• Lri �n9Z
Phrsicld,address.City.and Zip yr RCMARf:S:
Chatham Bentonite seal: 5-8 r lnffomcc n Pl*=c,,9;jfj
Caaul]' Parcclld rdifitUlouNa I'P1N'I
Sh.Latitude and Longitude in degmcstminuMsAcconds or decimal degrees: 22,("ertification:
(lfocll fold,Ors I+m'lottg is satricictd)
N W "r_� 5/1/2022
Date
6.is(are)the tvell(;s} %Permanent or OTemp oran' as• n;. f .r-m'c -a
N .r,•rain,fhir u,,.: r•.! ,rir •� '::,s,
rum7nrclyd iv rca•orrtrnrr
rtfr,l 15,1 NCtC 02C J": ;;X.02M Ri'rf C(mmyerrfou Srnrxlarrtla avid Akira
7.Ls this a repair to an eustin);well: ElVes or K Nu r[pr ofdiir r,e+rrf bar ht ee,r+rm'irh',i r,�u w;n!!ra,r,ler:
1f this is a.. N11r.fiill(wr krmaw+riff rnnsinmioti i nfortow den ar,d explabl rho norttre of rile
relu,•ir moiler r)21 remard•.r.sce.•fian or mx,the bock of thlr form. 23.She diagram or additional well details:
You may use the back of dais page to provide additional,,veil site details or%veil
8.Number of wells constructed: 1 CU1191mC[i0ra details. �rUtl r[L]y also aftaclu additional ptbs if moat essan.
For ntahipfe fajeedon err omi-ioclrrr rapjr 1,rvdfs ONLY$0cf]61'some eoRsh ueflvR.vr,ir eao
.%abmir-110 forur. SUBMITTAL iNSTLIC.TiONS
9.Total well depth below land surface: 25 (tb,) 24% Fur All Wells: Subndl this funn within 30 days of completion of hell
For,wOlpfe r..elh lfu ail r5+prhy ird1J}i•1101r leaarrnpfe- (1!r auul err frN)'y construction to oleo foRn"ing:
10.Static eater level below top of casing: ((y,) Di- siun mf Water Resources,tnformatiun Processing Unit,
(lxMW hovel&aboor VQ501x.AM"4" 1617 man Ser1'ice Center,Raleigh,NC:27699-16 L7
t.Borehole diameter.6„ (in.) 24b.For 110W.Ion Wellc ONLY: bt addition to sending Ilse fonu to ilia address in
24a abtwe. also submit a Copy of this forin within ?O days of completion of tiell
12,Well koustruction method:Air Rotary consimetima to the following:
(i.c.au-gee rosary.cable.dira:t posh etc.I
Division of Water Rc4ources,Underground Injection Control Progntnt,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail.Service Center.Raleigh.NC 27699-1636
134L Vidd(Upm) 4lcdrod of test: 24c.For Water Supply&Injection Welts:
Also submit one copy of this form within 3a days of completion of
13h.Disinfection type: Amount:. well construction to the calmly lucalth dcp: countyent of the county where
------ _. comstnuctcd.
Form GIV-L tlollli Cafolim Depament of Efiv imuccinaid Natrind Resources-Divnion orA'aler R-m-umom Revised Augiut2i113
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