GW1-2022-09545_Well Construction - GW1_20221014

WELL CONSTRUCTTON RECORD
TM5 rorm can lb owd fcr sirgtrc or tmall ipl tcclls For kznaat Use ONLY: ++
I.Wail Contractor hdormatiou:
tJ 1, `FL"RZONES =
John Eisenman 6nOt1 t0 a[t9QTtttPrnfY }
1Vc11 Caaanctor Nataie R. All f
4439 R. A, I i
NC Well Cftttfxtiiio t�at+tc]
rrnntit to nr.AMETrrt ttncr wz' SaAi'Lr
SAEOACCO Inc 0 tG 19 tG 6" In. SCH-40 PVC
C:caawpxny Svaaaec ti5 I1iAlFRCA: Nf:.QR:iB}BI�G [t6emsat axeit fi5i t'
FROM TCI DL#ttCt[itt NtATEnL1L
I Weil CrinWuctinn Pt'rtttit#, 0 R. 23 ft. 2" SCH-40 PVC halt:Itgnauf axr:i=ncrriar[ .:.funn;Srr.FTarir. ce,ItyS7fpt.,r,d
R, tt. j iat_
3.Wall lsse(ehacknr1!uw
Water Supply Well: imom I to f�rtszrtzttn tirorsta�, Y rlttcf.Nr s"t eAtYntat.
t_I:Agti;itlturat C]I4ltmicifctLfattblic 23 A, 33 ft- 21= im .010 scH-40 PVC
OG90tltcttrral{llcatirta;'Cootiug Sttpply,l URcsitlenteal Wntersuppl+•(siogle) R• fG ita
01ndustrial-Couustcrcial 0Rccidan1iid AVhter Supply(slttrud) `t9`Cttt?Cs
Frtoai ro 3Lv'[BRLtG t�1rPLf Cf AIEIT Sil fnOL S A110tiNT Cl lrri" Cann n-Water Supply Will: 0 ft. 19 rG Portland I Tremie
Na
11manilaring pl eavc�, 0 R. 19 R. Portland ITremie
Injection Well: h, ft.
ClAgiriferficclulrgc 06rouftdwmerRcuicdiatian EYgx1R4NDIGILI VPL,tkACW1ira itt rttl
0 qulfcr Storascalw Recoven' Wilinaly 8arrirr Fttnkl tits uettlttrtt. h�ipt 1Cf'iE\7\9t tElgit
21 R. 33 R. Sand #2
13Agniti:r Test MStarnmater Drtan:t8c
13Fxpizdai tual TeclmolC+pc ia5u>tsidatcc Cowrot tG
1i1"11RffG1�[:+t C1[:ratta`eh xddltiiiiatt thrctst irreessnrvl❑(leatltsntftl(ClasctiLoop? GlTracet trnnt m pr5cttrpnticttp .tr�Wnc+v xrti„cbn cn.�ttt"
❑Cicotlrettu rt(1leatnl4'Coolitu l2etuur) pUtlter[ex 11au urtdrr t)21 Rcurft&s) See gRo s log R I'
4.Date Wet(y)Cumpidted: 9/13/22 %Vell 1 #MW-22
tt. A.
52,t,at I.tacatton:
Honeywell
Faeilityltntrvarr + .i 7
Fardih•ID:,{9fapptiahlc} ft, R.
636 JObn Riegel Rd., Riegelwood, NC, 28456 ft. tG ®L r y
Phssiimd Addr.-w Cite-:aml Zip
Columbus 13entonite seal from 19-2I'
coutill t'MU01idniirvewi0ttNo [VINt
51).Latitude and Lon in dLgnxs/minutes/se etlnds or decimal degrees
i 1 32.Cettif'tcaNan:
;f atc1 t;;ld,l"w 1.10oa y is sadficf.n[1
1
N w a 9/19/20 22
6.is(arc)the well(sl: ZPcnn:tnent or ElTcmlmrars
lie srr,n¢=� our tar -'tr L;Pc/�ttk � �.�?rs.rs arc+:. ¢vrrslr;rrlrvY arr.cek�atPtinre
u attr l,S.d hC1tC Q„{ ,r. , {�� r_,f YW 11 al s eustn.s d as Skira liar is urrJ rlraif rt
�'.is flits a relmir to an Cxiating wall.. OWN or XNn e'��n=nfrAir rr;•.raaf dtrxti l c.°i t rrtr r?rr;rr+alre,rap't rncntr .
If 4;6 i5 o aatartb fiii tut 6?mIJa tuff cot nit,tit 0rtfvivkifd9ri w,Jl it (lia't ft;rtary„f Ill r i
reeiafrrouder021 rrrwcbr aerrrem or im the 1)t".of lima'ft 23.Site diagram or additional well'det tit'1:
Yc.0 may rise the back of this 1xtSe ko ptor,idc additional well sits:details or well
t3.tlutuberof wrlls ettttstrttitc�rl: 1 eousuuction detaaits. You nmy s>`w:uaaeti atdditioual1xi�s if occessatg.
/nr iiiutr,*,nlr ir,r'<t�lkai or rar!ar-nxrer term=iertts d>a!l i'rrirli t'iv Sartraaearrstruttlhar.few«rra I
sr 6ndrmne foma• CEt1IhIi7"1'�11.t1VC`�t 17p1�*C 1
9.Total well depth betow land surfacer.. 33 (fl,t 34a. Ftir All Walk Subutit this Iftanu within 30 days of coutpIction of well
Fm=»rarhiipfsa u•e?is Nxt et:dMarlar rfd{M•rrna&xrniFie-'i-1-1i—Tr arae121511wf's Construction to 11w rottottin6. '
I'
10,statle water k-vvl below trip of rasing. (lg,l Dis•is€an of Water Resouraem Information Pmcessin-unit.
tf wwor tev"I kv,;mce lostoz case"+" 1617 5lail Service C'cater.ltiticir,fy if"27fi!tl-t617
11,Bureholydiameter.12.25"/6'" (la) 24b. nr Iniictifirn Write ONLY: Eft iiddition to sending(k,fond to the address in
12.AYcll r[euctruction mMitod:BSA/Mud Rotary
v-laabov'a also Subtuit a copy Of liti 'foitu within-10 days of completion of 1►>:lt
Cet[sarnctiau to tlix f011alling: f
ii.c.au;cr rotiat-,cabic direct ftasli.et.t
Ph•1slnn of Water Resources,Underground Injection Control Fron It,
FOR WATER SUPPLY WELLS ONL1 163614i t11 Service Ce k teir.lialei;h,NC 27699.1636
f3u.Virld(span► ti►�tttad of test: 2dc For Water Suggiv.@ fuiretiifn SVetCv:
Also submit ow copy of titis rafm iritbitt tp dat•sof completion of
13h.Disinfection o'pe-. ..,__..._... _ _ Amount: _ welt Construction to the calm1=11h ideparfroeut of ilia Cotutlp zncrre
cowstnrcted j
Fowl OW-1 anti CWrallaaa rhpantrant u[Snst[flma at auai Nahars!Rcsaiutccs_DiraiLars of 1Yalu ft ate fury iced>1,L r Wus1_pl3
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