GW1-2022-06729_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD Fitt-lrtontulUsoONLY:
This form can Ki used(w single ar mullipk aeils
1.Well Contractor Information:
i4.%VATE1t ZON IS
John Eisenman FRONT TO I OF:St'RIPTION
'W01 CoricactorMum A.
ft. ft.
4439A
NC WcU Conlr.!clar CCrlificatitrn NILlibCr 15,.OUTER CASING(for mull eased wd10 OR LiNER fit auttfirabkI
FRONT TO I DTA.%IETCR THICKNESS NIATERiAL
SAEDACCO Inc 0 fL 101 IL 1 6 -Jill. SCH 40 PVC
cmnp:ua.Name 16,INNER CASING OR TUBING' tK!tberlrlal dos;M-luv)i
FRONT I TO DL4.HETEW I THICKNESS MATERIAL
2.W01-Construction Permit R; N/A 0 ft, ill Ill 2 � SCH 40 PVC
List all r jU71irnhl,-w4f pr,mitr"/e_r.:Crnrnh;Star,•,Vuriarwe,ley--r?dcn eL-.') fl, I ri, m
3.well.Gse(Occl:well use): 1Z 5Cf1t EN
itiatcrSullpls Well:
FROM TO DUMMETER %F.OT SI73. T111C1Ctii$y -NTATRRI,a I.
C1r gkulttlnll no ft: 121 fl..{ 2 )n .010 SCH 40 PVC
❑Gc ftrnlal Weating`Gooling Supply) bResidential Water Suppt}•(sing10)
OludustrialiComawmial DResidcntial Water Supply, FR
islnald) GROUT
E' ONI I i0 NIATERW. ENTP[.ACENIEYT3fI'fflOnfi.1N10LT�NT
❑lrri"ation 102 `.lL 3 ft: AquaGuard ,Tremmie
Non-Water Supply Well:
3 ft.. 0 ft, portland pour
6 Moltitoring- ❑Rccni-cry
Inject on Well: ft. I'L
❑Ailnitcr R46h irgc 03roilr>;1Tr,kr Rcinct;160-1n, ig.SAN bl(;Rk%VCL PACK Iif t tlichbte)
` "FRONT" - TU 'ITATF,RUIT." F7NTPT.A(-t:NIF%T NI17n01)"
❑A[jtrif�r.S(t�Ta C ai>i Aic 4ti'4 ❑$alinijy Ban Cr
S �' 121 ft. 107 A. SAND #2
❑iaclilif�e Test ❑5tomi�satci'11rilnag�
ft. fi.
❑ExPelimcntal Ta:hnc,logy ❑suhsidcticc Control
20.DRILLING LOG(allacd udditional'sbeela if nrcessarr•l
❑GeothelnT 1,(Cldsed Loop) ❑Traerr -FRONT.° TO DF;SCRIMON(whir.barditcv,wil,'ntck(i Oh we.cif l
❑G:*o"ttelnlal{Hiatin�+Cool'tu>?Return). ❑Other(esploin liltider tJ?t Relaalf s) 0 .ft._ 17 tL soil
17 ft.. 22 ft: PWR
4.DaCC'wNll{9�CUtI1111Cftd:- 3-2-22 Titi&IJD# I1W-32C
22 ftr 121 fL Bedrock
54 Well blcatinlii
Corning Incorporated N/A
rL Ft. J U N
Facility"6vivrNamc Facility TD {ifappi able) ft. It.
3900 Electronics Drive - Raleigh, NC ft. ft
Plry=,ia11 tilde ss City and Zip 21.RMARM,
Wake County 1715781482 Bentonite seal from 107-102ft.
Counly PJM0lr11.31if6249litm No.(PIN)
511.i;.RtltU'de"Anll-LO-Hg-Itude ill(IC'R[PeC 1RItil1t1G3�SC€Qn114 i7LdCCI1r1Al("rees, 21 CT't7f[C9t11YRT:.
(irmt: ,lxlJ;0iw1:1tlo izmallCRnf)
35.832589 -78.604500
_3/2/2022
Sigtlltti of"? =h'_���7f"ir; ±! .•`— — Dale
6.Ls{arty the Tt'CII{s): giPtmiancnt or ❑Tcu►poran' Bv.]igriJ,t i i�ar f tx,rsrinrcic�l ire.rriY'ardrrni'r
wWr JS:I,VC.,SC OTC:ix=' =t 7 7 C n�= C.d7 40 WWI Co,lsmotafan Sta,Lklyds mid r&-,j if
7.Lr this4 itV lairto an,esistin}n•cll: �Y (ir MN(i. cgjir;frhf r,•rriniJiasbern pn;rith-tl i,n'e oTH cnr;i�r.
if yus4c n re;)z0r,;T1J rr, Irtt,i,ii iirfart-urcort twd r_inJain'rhe moire njrlie
mt,,.rr rurJ,.r 921 rernuik sr:c.jkm r,r Ian the bte.(i±t Hero fnrnt. .23.Site.diaNrjlwor additional s.vell defails:
Ir611 toa}'use it 'bnR bf"this page"io-jltticicte:id"ioml well site details-or Will
S.Number of wells"constructed: 1 constmcticif details: 5 ou may also attach additional pates if lrti;essan%
Poe ot iiwa i"l'ci'IJntl"or owi-it'clier-Ck&4)l ni'ils ONLY 1601 the Mine
eariratrtrititt,r:}ice c'cma
c,u,ndt a�nc jriria+. SUBMITTA L.INSTLTCTTONS'
9.Toittl vell quh below land surfaime, 121 ({},) 24% Pur All-Wells. Siibndi this forin n•ilhin}(t days of Completion of hell
Fc-toil Jr7,Adiic'.1if7iMofdri.'.rhsijdrerf�,ii{caret+,ri;le�-1 ?(J!�'euuJ3 �/ !'iy tonstnletiaiito"thcfollo"!ng;
10.StaticAvater level bolo v[up of casiiit;. at.) Diiisiun of W2tcr Resnurces,,lnformatinn Prucevong Unit,
If'u'arlrt level is rbota ewisg,we +" 1617 Mail3cnice Cintcr,Rrlcigh,_NC 2 76 99-16 17
!I.BnrehDlc diamefcr.l2/6 {ia) 24lt,For i i tlllc ONLY: In addition to sending 111.foml tr7 IN,addrea9 in
24a afyot'e: also submit a copy of this fonn within 10 days of completion of weil
12.Well ColtStnIetioll Metiled: HSA/Air Construction to.lite fvtlonallg:
(i.e.augm rmasy,'-cAle-diin t Push.et•z.)
Division ofWaler Resouriles,Underground Injection Control Program,
FOR WATER SUTPLY WELLS ONLY':" 1636 Mail Sen•ice'Ceiflcr.Raleigh,NC 27699-1636
133 yield(aPm) Mctiloil of test,• tat~Fill-Water 5u;lply&.iNectinn W clts.
Also submit one copy of tins fbfnt within ;l) dagsofcolupleiiduof
13b.Disiuf(xKinn hpc: Amount AvcH cuaslnlction to the county Ite6lih depnrIniml of the colinty where
�t7n41T11Ct�i1--
Fa flit6kY-I. NunhCatalinaDe-paruixntofEmimMiclnand'NaiuralTt�s3trr^. -•U(liitOQ4f4�ralcrR�trce Re,iscdA gust It?I?
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