GW1-2023-02556_Well Construction - GW1_20230410

F WELL CONnRUC[TION RECORD Far[ticmaJUseONLY;
This form can be used for single or Inultip}e wells'
`f 1.Welt Contractor Information:
i�TER'LONI'S
John Eisenman FROM "I bricluptuyN
Well COVAr+CtOt M0110 ft. ft,
4439 ft. ft 4
NCiYcllCotmadorConif(calionNunber IS.-OUTERCASING(Mrriiiiitki,'d"ikl`1 'ORLINER'ift lica6kJ`-
FROM To ori,%R..Wrt WOMI- 1i' s \rATERtiI.
SAEDACCO Inc 0 ft. 35 (L 2" JIL I SCH-40 PVC
t•a,!,L,;i,!t.Naa� 16 INNER CASING OR IHING:4 oit6eirnnl duxcd4oltp
FROM I To KNAIFTER I TIFICKINESS 'MATERML
'.SYc1t"Coostt7tctilin['cl alit k; R. ff, pu
Lister!!a�lieabf.�rril primirs tiara.Cntrntv..Sttr+c,t•�+riurar,fl}reCdCi}err./ eft. fl, [n.
3,Wi7iI Use(chccl.well use); 17.SCREEN
Water Sullply%Vaq�ll: FROM TO DraarM_rt sts".8trs; Ttncx�rss 1 st�rnRrnr,
DAgticulturd► FJi4luniclp%Aftbfic 35 ft, 55 ft- 2 in. .010 SCH-40 ' PVC
r1Geothcrmal dicadnft+Cooling Supply) ❑Residential Water supply(single)
©IudustdaU£omutercial ©Residential Water Supplg(sikltrd) t8 GROUT:
FROM 7O. MATERML I EMPLhCE\iGNT MGfIIOD S AMOONT
❑dtri�atiun 0 it. 30 fit. Portland Pour
NnuA4ater Supply We'.1l:
wManitorina pRcta%•cly
lnjcclion well: ft. fL.
QARuifcrRcrhagc QCJrotuid aicrRcmcdiation 19.•SANDIGILL%,TL'PACIZ{ifuleiicnbttJ'.`
"6'R457 t0 RLt'Cf'.Itt41. RSIrLtCE\firs\T31!'t'PIOn
❑A.quifcr.S(omgc ar,,i Rccovcry ❑Salinity Aan'icP 33 R. 60 ft, Sand #2
❑Aquifer Test 1151ortn8vatcr Dminagc
rL. fit.
❑Eiy)e[imcntal Tcihnology QSubsidcnce Control
20:DRILf 11G'lAG"(attach addltibnal sheds if nrttssnn'1
❑kotltennal.(ClusedLuop) ❑Tracer FROM TU MirRiPTION,( br.haWNC'M.t+•Rh.K4n . "n!t,+c,dr.)
❑Geothetntal(FleatiuuCoolineRetain) Miter(explain under 02t Man ' 1 0 (t. 60 ft, Silt/sand/clay
It. fL
4.Date Wel(s)Coulpleted: 2-3-23 Well ID#MW-12 ft. R.
-
Sa.Well Lltcatinli:
Speedway fL fill APR. 1
act3iip;OnncrVanes Fad1hyIM(if applicable) ft. ft.
4431 N. Center St., Hickory, NC, 28601 ft. ft, 'ae' ' '" fiats ^^r-rt
G•ra t�:"tea.,��
F 11N timt!Addrss_City-and Zip 21.REt1L1RI{5'
Catawba Bentonite seal from 30-33'
4ku+n1� Parcel lrl_ntirrGdiou Np.(?IN)
:'+b.Latitude and I.ongitnilr.in 11cgtceslminutcslscconds or dccilnA(!egress: 22,Ccrtifeeation:
(i1 null field,om latI)og i;;I[Mckid)
2/22/2023
si�turr rug - -r �fart'U.��
6.l5(arc)fibstisell(s}; XPennanent or ❑Temporary Hri{.g+iit rFirfa+,"r:'r':�� if !n + 'i si 7 ze.r�rruererl5rrcYonlrncn
I1-0 15.4 Xoic Olt" -iz;,—1;—CAC.w'C,0200 ni'U Coustr;+r;ion Sraa larch Auld dM_r sr
7.Is this a reiiairto an eiistingIvell: ElYes or KNn ca,�rcjdiir:,•rdniterisla,ra lrr:yrided rnlh,e n,rli rnener,
if r1r{sir a 41-m7k.fill qjr trron7i weal cra�7+trrlinri irrjorrav t;on mu!e.t�ta;n rla rk;rter;of rf+c
repairrarelrrO21 rrviarks sm.-fian ar fM the hark pf(iris farm. 21 Site,diagram or additioual yr eil details:
Y 6u may use this back of this pa&to provide:additional well site details.or dell
S.llumberofrsells coustrueLed 1 coltsnuclluu delaits, You inati'uL :tit icitadtlitiatlal p<rbes il'mx van.
For nudrlple infeeriirn or aryl-weuer rapt l)-rre(h 011'L1'n•Uh rbrsrrme cm7srrtrcfFwr,ysa ern
sap+n&am fame. SUBMITTAL.INSTUCTIONS
9.'Q'otal'n•elt depth beto%r land surface: 55 (to.) .2.4a..Fur All Weilm Subndl dds fonn within 30 days of completion of rsell
For nmihlpin,l•UsRirafldrrrhsrldif.erk,u(s•raR 1pk-3CA-2 O'and,2@1fm)') eonsinictiontotltefollonin5-
Iu.Static water-level below top of casing;; (ft.) UivEsion yf W.jter Resources,lnformatiuu Processing Unit..
if Ceder level b ubore raiia_i+se +" 1617141ai1 Service Center,RAlcigh,NC 273699-1617-
el,tim'chotc diametcr.8.25" (in.) 2.4b.F-hr IliiM11011 VieRth ONLY: In addition to senditi;.1he fonR to the adores in
24;above.also submit a copy of this faint within +(J days'of completion of%till
12,tY'ell eonsttttctiml method;HSA collStmelioll to the follo%vine_'
(i.c.auger,.rotM%cable.direct plisk e(c.J
Division ofWatel'Reseurces,Underground lnjectio"Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mull Service.Center.Raleigh,NC 27699-1636
13,f Yield(}qim) 24e.For W;Itcr Sultlily&Injection�Wct1v:.
1'ictirndoftssr Also submit we copy of this far in within 3A.dpysofcompietion.of
flab.llisinfictiun type! Amount: %cell construction to the county health department of the county tvltcre
sonstnlctcd.
I
Form GW-L tN'onh Crmlina D pan=tti of£uvin,mm is and Natural Resources-Division of%Pater kMLEM Rin,ised Auguu 2013