GW1-2022-07647_Well Construction - GW1_20220818

_ WELL CONSTRUCTION RECORD For Gacnid Use ONLY:
This ronn can be owd fm singic or molt ipk wells
1.We l Contractor Information:
14.AVATER ZONES
John Eisenman WHOM TO I 0MCRIFT"M
W01 CotMctctor Nary R, R,
4439A fit. fit.
NC Well CammoorCcrttficationNumber 15,OUTER CASING(For mithi•ea>x;der9 ORZ.iN�t 11- ucabir
` _~ �a L4F*�*® Tr'AAAI TO D1Jtl� it Trlt F VL55 MAMMAL
SAEDACCO IncEE F! Ii�� 0 ( 20 rL 2" is SCH-40 PVC
Ccmpttm?Name 16.I IMM CASiNG OR INGtkeealkernfai elacedavn
AUG 1 8 2022 FROM TO DPAAW-TER TMC NFSS MA ERIAL
2.WdI Constnmctlon Per7nit 4: ft, ft, hL
Lim all appilicuble toll pennitr fi-r..Cmrnttr,Stale., rnr"n ]�� rt�j vii30Ct1�1 Ufft fit. p, ¢n.
3,Well Use(chock well asc): D1.'1Q1B0G 14:SCREEN
WaterSnppig Well: I MOM TO DIAMETPR SNOTStM. Tn1MN*'S I MATRRtnt.
G]Asricultural 0Munieipau tlic 20 R, 30 R, 2" In. .010 SCH-40 PVC
Mvolhetmal CNealing/Cooling Supply) DResidential Water Supply(single) ft' fL ttr,
®lndostrial✓Commercial ®Residential Water Supply(s1a-md) wxito[1"i
FROM TO MATERGIL ENM ACEMENT AWMGD&AMOUNT
❑ln-i Atien 0 n. 15 fL Portland Tremie
Non-Water Sttpply Well:
MMOMtodn ❑Recovc R rt
Injection Well: fL tL
❑AtpuifcrRccharge 06roundwattcrRemcdiation 0.SAT1t11t;IIAVE'I PA(1ZMarmikobtel
PR M 7 MATP,RPAI. RMm IA .�i MmE—ritt1
QAgiiifcr Slorrgc and Rccolrry ❑Salinity Bamcr 18 R. 30 ft, Sand #2
❑Agdlfcr Tcst ❑Stomm'atcr Dminap: R. ft.
❑i:xpcdmcntRl Technology ❑subsidtacc C034Ml
Is DIMUNU LOG(git -vddMo*d,ik-dfl(ftmYan1
❑Geodietinal(Closed Loop) ❑Tracer PROM I To DEsr.RtrTTo, aorar,har2nen anMlrs�ck n tsraerat
❑Geotlienual(Heath f2oti ill Retum) ❑Other(eo0airt under#21 Remarks) 0 ft. 30 (L Sandy clay
fit, ft.
4.Date WOO)Compleled. 7-19-22 Wetl ID#MW-3R
n. rL
5a.Well LOCathln: IL ft.
Former Ardee Translite fc fc
FnciiityX)ivncr Nunte Factlh)•1D#('if sppitubic)
639 Washburn Switch Rd., Shelby, NC, 28150 R, fit
Plgsied Address.City.and Zip -21,REMARKS
Cleveland bentonite seal from 15-18'
011111l)' Partd Identiritrntion No.(PIN)
5b,Latitudc Arid Longitude in dcgmc0minMa/nTe nds or dccimtd dcgrecs: 22.Certifeeation:
t.if cell Wd,de te0ong is SnIlicient)
1\ W - � ' Y, __ 8/i/2022
Signttrtrc of t,c�... ��o ter• —_-- �� DaIC
6.Is(am)the well(s)i MPermanent or ❑Temporar N `fsX
M,m•eignb q thu fni,r s of :Y was 1.:r. i:unvrnre`terl in mxom4m[x
with 144,vCAC o2c. '� -1 e" t n�„li.OsQt7 Well Cojwrverfm Srnndards owl fiurr o
7.Is this a repair to an axisting well• oyes or IMNo ropy p(rlik rer•onl huh'brnr prminrtd.to the strll mo ter.
if ihfs is a repair,fill omr hrromw well"dSTrlKW#n infomwrifm mul r•.vpfoht rhr tarrxre olfie
relrnir tuoler 021 remarks sr aim or an the bark of this form 23.Site diagram or additional well detaffi%
You may use die back of this page to pro%ide additimW well site details or we]I
S.dumber or wells consiniered: 1 constiuctioo details. You may also anach additional pages if necessavy
For mxMple bt/ecrhui or nrot-warer atppir wells ONLY w1rh the mme evirarrlri•Smt.,vox e4m
.mbodrmrr form. SUBMITTAL OMUC17IONS
9.Total veil depth below land surface. 30 (n,) 24a. For All Well Caibinit this form Within 30 dnys of completion of well
FormaltIplr wells lisralldryrhslJdif}ire+u(cxampk-fi�+20t7'aHfZ�ld1(i'i constnlctiontolhcfollowing:
10.Static water level below top of casing: fp1,) Division of Water Resoume%,information Processing Unit,
if haler level is odwve wSing,use•'+" 160 Mai[Serviec Center,Rluleigh,NC 27699-1617
11.ilomboic diameter 8.25" (in.) 24b.ar ja&llan Wetls ONLY: in addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of Weil
12.Well construction method: HSA cmisinictiou to the following:
(i.e.auger.rotary,cabie.dimat push ctc.)
1R(<-irlon of Water Resautces,Underground Injection Control Program,
FOR WATER SUPPLY 1VELLS ONLY: 1636 Mail Service Center Raleigh,NC 27699-1636
13a.Yield(gpm) Alethod of test; lac.For Water Supply dr injection Welk:
Also submit one copy of this farm within 30 days of complet ion of
131),disinfection type. _ -_ Amount: well consirction to the commly heabb dgmrm=nt of the counh•where
consmictod.
Fenn GW-1 Nonb Carolina Depwinvin of Ent irmunciu and:i in"Resourtcs-Division of%tcr Resoiross Rcviscd AttguSt 20 13