GW1-2022-05484_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD For irucnu l Use ONLY:
This form can be used rt}r single or ntultip}c wdis
• 1.Well Contractor Information:
:'IyAVATER ZONES
John Eisenman FROM To pE.ImPin)N
Well Contractor Karw
' R.
4439A ft.
NC SYal1 ContranorCcrtifnmion Number
IS,OUTER CASf�7G aroi etuTit¢aseiB'w'clls MA
OR E iNER':(if_s'iF(cabfel
FROM PF
O pt,1METER THICftNESS MATERTAL
SAEDACCO Inc 0 tL fL 6'r in. SCH-40 PVC
Caner un Nanrc E6 INNER'CASiNG'OR-TUBING: oJ&--rtnal duSid ton' i
FROM TO DEAMETER THICKNESS MATERIAL
2,Wclt Construction Permit 4: 0 R, 57 ft, 211 im SCH-40 PVC
Lfsr all a}plirabfe Mv11 pe-ntvtr ri_r.Cowev..Stwo,Varirtrree,frya'dC4 err.
3,Wc11 Use(Owch:well ase): T7:"SCREEN.;
Water Supply Well: FROM To DrMIMIr it I SLOTSITE ITlrl('KYf\S \t,4THR6�r,
1jAgricultural riNf ,lnicipuaRlabliC 57 ft. 62 ft, 211 in, .010 SCH-40 I PVC
015cotherut'al(Heat➢n `Coolie Supply) rJResideotial Wafer Su R, ft in
3 g Supply(single)
❑btdustriaVContntercial DResidential.Wacer Sapph•(shared) ;t t::CRO[tT
FROM To �IAEEREIL EMPLACEMMMEM10DdA.MOUNT
❑Tern atlml 0 R. 44 rL Portland tremie
Non-Water Supply Well:
MMunitoring ❑Recovery
Trajection Well: R. rL
QAquMr Recharge QGrouralR;rtcr Remcdialion t9`SANDIGRAVELPACK(if a Wicafifelk
FROM To st,%x i.Lum, F:SrPI. C.M1 F:NT M1:HOIJ
!7 4quifcr Storlgc alvt!Rcca«I}' QSolininr l3irdcr 55 it. 65 R. SAND #2
❑AquifcrTcst ❑5tormtvaterDrumgc
❑E.Vcrimcmil Tcchuology ❑Subsideucc Condral _
l(L'DRILLiNG'LOG7atticliadditionale(i&cOfaccesm6Y,.
❑Geoiltemml(Closed Loop) ❑Tracer FROM TO MCRIPTION(i»br.lmrdnccr.sk-WrtA h rr. 'n vrre.dal
❑Geothemaal MeaiiuglCooliue Return) 00(hLr(explain under 921 Renmr&s) 0 ft. 30 R, sand stone
30 it. 65 ft. rock
4.Date Well(s)Completed: 5-2-22 Well iDOW-2 R. IL ' -.. r-c
5a.Well Location: a
fL fL
Circle K 4660 R. fL _ 2022
FacdityXhvtrcr Nnnae Facility iDk(irapplicablc) R, ft. _
lrifaEmaka}bra-.,=-aMR lurch
1513 E. lith St., Siler City, NC, 27344 ft. ft. M"VO OG
Physical Address.Cite.and Zip 21`RENIARKS;
Chatham Bentonite seal: 44-551
Cgauty IsarcC]Wnifirkzalimi Na.I°IN'I
ib.lattitude and longitude in ticlpres/minufcs/sccands at,decimal degrees: 22.Certification:
(ifwelt Bold,Orel Irrtrltrug is gtsflieical}
lti W !=' 5/13/2022
Ewe
6.ix(arc)the wdI(s): MPennancat or ❑Temporan' Br s.'y»nr hie foJ,i F`:r+G: i(• f sr<'Ma �a�!• fcJ rr��r rnrt 1r[l ire rrcrccnlrn[z rrirh 1 fA NC'AC 02C. -; 1:.:<i(:rf..;zc.02M)owl Consertctiol$rneulanlc told rhar a
7.Is thN a repairto an existing well: OVt`w or NNo rrpsofrlih reward husbeca prrrt7PW rntLa,nvN mmtrt•.
?fools is o ngwir,ryll a,r Alrurlvol uved rrru7rtn°tiort irtforrrgrrtvi tiori e!,Irkrht the novire 4 f rliv
repair writer#21 remarkv seeriorr or co the Irrx•.t:of tfiLv form. 23.Site diagram or additional well details:
You may use the back of Unis page to provide additional well site details Orr well
&.Number of wells constructed: 1 construction details. You umv also allach additional pages if tic essay.
For rnnlrlple wjtvrhm or ejan-ourer ntplrfr Wrens f)rVLY irirlr all,snare eirtrstrtrctlo,r.purr C•410
saOnjit eme jorta. SUBMITTAL iNSTUCTiONS
9.Totat well depth below land surface: 62 (ft.) 241a. Par All Wells: Subutil this fomi within 3ti days of completion of well
Forrttahe'pir wdif lisr ell rleprbs ijdidivrw tcrtrenp(e- r,_N 1V'41IJ412QXyo') construction to the following:
10.Static water level below top of casing: A? Division of Water Resources,taformation Prucessing Unit,
1f never h-vd is rbnrr cnsiax,am"+" 1617 Nl;iH Sen'ice Center,Raleigh,NC 27699-1617
11.Borehole diameter.1211/6r' (in.) 24b. For iniccNnn We11v ONl,ftr: In addition to sending the form to live addless in
24a above. also submit a copy of this font within 30 days of completion of well
12,Well coustruction method: HSA/Air construction to the following:
(i.v'.auger.rotary,cable.direct push,eto.l
Division of Water Resources,Underground Injectlon Control Program,
FOR WATER SUPPLY WELLS ONLY, 1636 Mail Service Center,Raleigh,NC 27699-1636
Mt Vield(gpm) Malind of test: 24c.For Water Supply&irgicalort Wells:
also submit onp copy of this forth within 30 daysofcompletiotof
13h.Dis(nfceriun hpe:_.V_�.___,_�,_,_. Amount well consanstion to the county Lcalth depanmiyn or the county where
constructed
Fonn CI%V-1 Nrrnh Catolitt fxp tnn:lur uC Eneuatureru and Nanral Resources-Divr;ion of .mcr Rmotrces Reris<d,Strgtat V>I
I