GW1-2022-05483_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD FortiucnuilUscONLY:
This form can be used for single w mallip)c wells
1.Well Contractor Information:
-Ii::WATER'ZONIES
John Eisenman FROST TO DF ICRIPTION
WWII Cor4mctm Nanre ft, ft.
4439A ft. (L
NC Well ContstcrorCcnifocnlion Ntm)ber 15:'OUTER'CAZtNG Porniurikiied. citsl OR L(KER it a"n" k ;
FRONT TO PTAMMM R Tt1ICi:NFSS MATERIAL
SAEDACCO Inc 0 (t. 10 ft. 2" in. I SCR-40 I PVC
Coley wry Mane .16YINVER CASING OR=IIIBING aat6crrifal'cl6sed4on �'...:..
FROM TO DIALIIF.TER I TftiCKNF.SS hiATERTAL
2,Wdl Construction Permit R: R, ft, m
lesr all an7lirable well penrrits(i_e. Pariaaee,1rf2CbCn eir.) pL -
3.Welt Use(cheOiNvcll use):
Water SupplyWell. FROM TO I DIAMF.niR I Sr,OTSt7l: I THfCKIiFti5 I 1ATKNrAt.
❑A2ricultural tiMunicip:dr nblic 10 ft. 25 ft. 2" in 1 .010 SCH-40 I PVC
❑Geothemial(f3eatingfCooling Supply) ❑Residential Water Supply(single)
Oludustria fConuncrcial ©Residential Water Supply-(shamd)
FROM TO MATERLIL I EMPLOWENIENT HMOD d`AMOUNT
❑ItA than 0 fL 5 fL Portland Pour
Non-Water Supply Well:®Monitoring ❑Rccorcry
tnjectton Well: rt. rL
❑AquifcrRcchargc ❑GrounduatcrRcmcdiaiion 19[SANWGRAVECPACK(if'r'dicidrfe)
PROM TO MA'rF.RLir, F:�IPI A(:F\88:\T Nt:rBr(ln
i]Aquhfer Storage and Recoee(y ❑Salinity Harder 8 ft. 25 R. SAND #2
❑Agnifcr Test ❑Stounn-atcr DFninagc R. ft.
❑Experimental Tcchnolog%' ❑Sabsidcncc Com ml
'2nI�RII.LIIIG'LOG(attachadtGlionafslieetdif necvssiirtt:•
❑Geotltemtal(Closed Loup) ❑Tracer FROST TO Dn*CntPTIO'-([»br 1i rrdne++.x iVt tek a d,f k+.de.I
❑Geotltennal Meatina+Cooliue Retuni) ❑Outer(explain under 921 Retuadkss) 0 fL 25 t. I sand clay
ft. fL
4.Date Well(s)Completed: 4-28-22 Welt ID#MW-9
Sa.Well Location:
Circle K 4660 ft. ft,
�a
Facility','Onn:rName Facility'iDR(if applicable) ft,- ft.
1513 E. llth St., Siler City, NC, 27344
ft. fL
Physical,Address City.and Zip 2l RE51ARKS
Chatham Bentonite seal: 5-8• �•
Crmu+ly Pared idodificatlmr No.(P1N.t
51b,Latitude and i.ongitude in dcgtreshninutcslsecnuds or decimal degrees: 22.Certification:
(ltaclt Jicld,mil I;ulluug is urtlicicrd)
1\ W -.r.._...•_.. `��- - 5/l/2022
mow,:: -' -- Me
Sigtvtuscof :^=i?::.. ar4u��tt�s..`-_ -
6.Is(are)the well(s)t EPennaaent or ❑Temporan' `ti, •r, ra :. . a
Qr signir;;rho Prrr,r rf !�,•.. ,.rr rV ,•1„e,.y ew arinreled hr urronkaur
rvitQ 14,F NCAC O.C.•l+-+:��-1"�if4r��.;.:.'L�!7.:0!)ni'lJ Co!rstr,e[rion Sfci+Llardc aRul rlxrar
7.Is thin a repairtD an existingwell: 0V�w or ltl Not r yr} ;dais rrv'ottJ hrs'la cn pr,:>rir!+'!l rn rlr,nd1 nuap•r'.
ljrlr(s at a rq.Wr,fill roar kr,riuw will ernu7mcHorr rforow irrt and esoti i r1le m;rare of the
repair mrder,021 runarAw sm-fian or rue the bark-afrfiis jornt. 23.Site diagrirn or additional%vet1 details:
You play use the back of this page to provide additiotral well site details of well
S.Number of wells constructed: 1 _—_-.-_ _-� _- -- consttction details. You ular also atuach additional pages if nx- essarp.
For otalfif4e Irriavrhm m orui-wean nipph'wellsOt`'LV i0rfr rite somecnrrstruetlon.ye:r eoo
saomlr�jr jorrn. SUBMITTAL INSTUCTiONS
9.Total well depth betow land surface: 25 (ft.) 24% Fur All !'ells: Subudl this funn within 3t7 days of completion of well
For nraiNple wells licr a•tf depOn if de'err?tr anal?rm 10)'1 constntction to the following:
10.Static water level below tap of ca dug: (f.) Division of Water Resources,Informatian Processing Unit,
!f waver level is droee crrair<s•,au'"+" 1617 Mail Set-vice Center,Raleigh,N('2769'1-IG 17
11.Borchotc diameter.611 (in.) 24b.Fnr htiection W'clla ONLY: in addition to sending the foml to the address in
24a above. also submit a copy of this funn within z0 days of completion of[yell
12,Weil coustruction method:Air Rotary Construction to the following:
Si.c.augger,rotan..cable.direct push etc.i
DiviAou of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Seff ice Center.Raleigh,NC 27699-1636
13a.field(gpm) Mcdind of test: tic.For W;to Supply&Injection Welts:
Also submit one copy of this form Within 30 days of completion of
Amount:. _ well construction to the county,licitlth depannteut of the counh'where
------..___. constntctcd.
Form Gli'-t Nish Caraluat Demnurcnt of Eucrroluirm and Nnuual Resources-Division of W:ver 4�-owces Revised August_o 1J