GW1-2022-09183_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD For lrtcnurlVwONLY'-
Thts form can tt:used fix single or twilliple wells
1.Well Contractor Information:
Ii.WATER•ZONLS
John Eisenman FROM I 7o I OF-SCRtPll(IN
Well(:orgrrctot Tank it, A.
4439
a. Ito.
NC N011 ComrrctorCcnifrcaiioii Number 15.OUTER CASING(for mitt caisr i<e11{O LTNiR N`a t lka6k
FRO\i TO MA1ti.TF.R R Ttlt(l�V, �fA1T,Rrv..
SABDACCO Inc ft. t1.
(:ompuh Name 16.INNER CASINGOR tL_BIN(',gethermalelbxd4dop).
FROH f32
TO DLTNi7ER Tlll(1:\£CS �1.1T£RLU
2.Well Construction Permit k: 0 ft ft. 2 in• SCH40 PVC
l�sraft aly1/i.Wde rsrll,xnnib fix.C�innr•,S:u:r.tariaerre.14er6pt no.) -- - ----- -
f1. ft. in.
3.Well I;sc(cheek well use): 17.Sf;Rt£N
Water Supply%Vell• t rRom i Tp n1A%IFTr.k I SId►T%IYY. I 7HICHNENS I MATERIAL
15A)trieifhural LiMunicipaLPtiblic 1 ]
32 ft. 42 ft. 2 }n• .010 SCH40 PVC
0Geothenn:d(licit ingtCooling S nu Supply) 011esidcal Water Supply(single) tt. fL �n i
I.-I lndustriallContntercial OResidential Witcr Snppky ishired) ilk IRON 70 MA7TRt►t. t EdIPL,(lfiMENT MF,T11pa A AMphNT I
❑itri ition 25 ft. 0 (L Portland Pour
Non-Water Supply Well:
00%lonitoring ORcco\rI}
in eet on Well: rt. tt. 1
DAquifcrRcchargc L16roimd%%-atcr11cntediation I19.SANDM.RAVELPACKIN dwa-w !
FROV 70 MATURIAI. E�1PLAll yIENT�t1fi11QD
QAgaifcr Stor iFe atd Rocmrn Dsalinih Harrier 42 It. 29 ft. Sand #2
(]Aquifer Test GStomnsater Driinage
❑FNperimcittal Technology Muhsidcticc Control
} 20.DR►.U,*tG LOG'(Nfach additibnel 44rets itr mnmry
Mothennal(Closed Loup) I]Traccr I FROM to InF 5fRfPT1O\iiubr.h,trdn.a re1'nn 1.h tin wr Ar.l
❑Geothennal(licatitiip'Cooling Return) ❑Other(explain under 9211 Remarks) 0 ft. 10 ft. Silt/sand/clay
10 it. 41 It. PWR
4.Date Well(%)Completed: 8-5-22 Welllh#Mw-203
It. tt.
Sa.Well location:
Facilityj0%%trr Nome Facifily iw i,ifapplrablcl
293 NC-740 Badinr NC 28009 Sternly Countyr r p, .7,,, t;ng Ur 1
PIn sical Addtrss.Cip.:md Zip 21.RMARKS
bentonite seal from 29-25ft
(,oall1w PAleelitl::uld-[AknoNo 1Pi.\r
Sh.i.atitude and Longirude in deg-recs/minuteslsecnnds or decimal degrees: 22.Certification:
(if acll fcid,liter Lttlortc,k grdliei:nf I
N q' 8/12/2022
Signiwr,of +:&%z�A,;1. � :!ae --- - Date
6.Is(are)the ncil(s): EPennanent or oTemporar• /:- ` zt f C r/ r . �- ors ;�a
Hr sanir iha fur.. �'... ;....:..if.•�i;' ,:•:.q.a. n.r::,cnr_Ururrrri in rn•c✓rdanrr
wah till•VC:riC t)2(. +'�:>'y `,(.r:� .1'.tt,',t)'t{{'ri1 Clmslr•ritizu$rnr+,fnrils anri da'rt:e
7.b this a repair to an existin.n'ell: _lVcs or MNo Ce;!r nr rhic err anf ha.N-,-n/+niryfr.;rn',1he m-11 ak•nrr.
ffthi,*tF4-re►urir,fill ht tr fmw e.rli rY>r1tUh 77r7t1 Nrfi-ney7fN+n 6114 r•tfr1D14 61'r4:rrde f r14'
relnrirunfrr P21 or r»[the hank a/thir form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional(veil site details or well
S.Number of Dells constntcted: 1 coitstfuction details, You may also gltach additional pages if nwessaty.
F'et w.1614r irzkwtiorr or ai»e-tir'r,re r tilan�_s are•11i ONLY ride dir some rointrar hML t/>;c fcir:
•c:N.1tionr)onn. SURM1311AS INSTUCTIONR
rl.Total tydl depth beloo land surface: 42 fit.) 24a. For All Wells: Submit this forni nithin 10 days of completion of well
Voe wd iple wells 1iu fell drpsbi ij iftf,i•rew t+'rnnpfe- 7F•W grin 26"101)) eonstroclion to the folloning-.
10.Static eater level below top of casing: (ft.) Division of Water Resources,information Prucessing Unit.
ff melee lrel is Bhnrr rYrbrny,ax "+" 1617 Mail Service Center,Raleigh.SIC 27699-1617
11.Borehole diameter.l0/6 (in.) 24b.For inlWir►n WeQs ONLY: 'In addition to sending the loon to the address in
24aaboye. also submit a copy of this funn niihiu iU days of completion of well
12.Well construction method:BSA/AIR cotistmetion to the folloiyine:
6.c.auger.rotary.cable.direct post:cten
Division of Water Resourtes,Underground Injee(kin Cootntl Prtrgrant.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccntcr.Raleigh.;SC 27699-1636
13a.Vidd(gpm) Method of test: 24c.For Water Supply n injectior Welk:
Also Submit one colty of INS fonii within ;o days of completion of
13b.Diainfedion q Amount: well construction to the county health department of the cotntty elicre
consmicicd
Fa on CAN14 `onh Carolirt i DeVanr[ieal of Em immrwnt and N:rmral Resources-Dr uhm of Water Risovet5 Re%ised august 2011